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THE 

PRACTICE OF OBSTETRICS 



EDGAR 






. THE 

PRACTICE OF OBSTETRICS 

DESIGNED FOR THE USE OF STUDENTS 

AND PRACTITIONERS OF 

MEDICINE 



J. CLIFTON EDGAR 



'V 

PROFESSOR OF OBSTETRICS AND CLINICAL MIDWIFERY IN THE CORNELL UNIVERSITY MEDICAL COLLEGE; VISITING 

OBSTETRICIAN TO THE EMERGENCY HOSPITAL OF BFLLEVUE HOSPITAL, NEW YORK CITY ; 

CONSULTING OBSTETRICIAN TO THE NEW YORK MATERNITY HOSPITAL 



SECOND EDITION, REVISED 



Witb 1264 Ullustrations, including five colored 
plates ant) 38 figures printed in Colors 



PHILADELPHIA 

P. BLAKISTON'S SON & CO 

IOI2 WALNUT STREET 
1904 






LIBRARY nf CONGRESS 
Two Oootes Received 
AUG 11 1904 

Ootyrtfht Entry 

CLASS ft- XXo. Na 

9 o U 1 1 

COPY B 



• '-* 



Copyright, 1904, by p. blakiston's Son & Co. 



PRES8 OF 

WM. F. FELL COMPANY 

PHILADELPHIA 



TO THE 

STUDENTS OF OBSTETRICS 

OF THE PAST DECADE AND A HALF, WHOM IT HAS BEEN MY 

PRIVILEGE TO INSTRUCT, THIS BOOK IS 

DEDICATED BY THE AUTHOR 



PREFACE TO THE SECOND EDITION 



The exhaustion of the first edition of this Practice of Obstetrics within four 
months of the date of its publication, and the many complimentary reviews 
which have appeared and personal letters received by the author, have been 
most gratifying, and I desire to express my appreciation of the fact that my 
efforts to present the subject of obstetrics from the practical and clinical stand- 
point have not been entirely unsuccessful 

Too short a time has elapsed since the appearance of the first edition to 
make necessary a complete revision of the work. 

i. Under Pathological Pregnancy will be found a section on "The Toxemia 
of Pregnancy," and under this latter subject I have placed, (i) Nausea and 
Vomiting, (2) Icterus, (3) Convulsions and Coma, (4) Eclampsia. 

2. The section on Fever in the Puerperium in Part VIII of the first edition, 
which included Puerperal Sepsis, has been entirely rewritten and brought up 
to date under the heading of Morbidity in the Puerperium. 

3. All the colored plates of the first edition have been remade, and three 
new ones have been added to the second edition, namely, two of the Toxemia 
of Pregnancy, and one of the Stools of Healthy Breast-fed Infants. 

4. It will be noticed that many of the illustrations of the first edition have 
been redrawn, and that forty-five new illustrations have been added to the 
second edition. Some typographical errors have been corrected and a number 
of minor changes made throughout the text. 

5. I find it necessary in the present edition to restate my position regarding 
the indications for Embryotomy and Caesarean section which from the stand- 
point of laboratory and theoretical obstetrics were apparently misunderstood 
and therefore criticized. 

I find it unnecessary, however, in the second edition to change the relative 
amount of space devoted to Embryotomy and Caesarean section, namely, eighteen 
pages to the former and eight to the latter; because Embryotomy comprises 
eight distinct operations, many of them complicated, and some of them fre- 
quently performed upon the dead fetus, while Caesarean section, on the other 
hand, is a single and simple operation, and not so frequently made use of. 

It is a far cry in obstetrics from the theoretical deductions of the library 
and the laboratory to the clinical conditions we find at the bedside. 

The amount of space devoted in the present edition to the Toxemia of Preg- 
nancy does not imply that the existence of a universal toxic pregnant state is 



vm 



PREFACE TO THE SECOND EDITION. 



yet established or even fully believed in. The subject is daily assuming in- 
creasing importance and interest, and it is to be hoped that the physician will 
study his cases of pregnancy with this possibility in mind, will record and report 
his observations, and will especially give his patients the benefit of any doubts 
which may arise when the question of a toxic state is in any way suggested. 

I desire to express my indebtedness to James Ewing, M.D., Professor of 
Pathology in the Cornell Medical College, for much valuable help in the prepara- 
tion of the section upon The Toxemia of Pregnancy. This section was printed 
before the appearance of Dr. W. S. Stone's paper upon the subject. 

Again I wish to thank the publishers for their continued generosity and 

courtesy. 

J. Clifton Edgar. 
50 East 34TH Street, New York City. 
June 1, IQ04. 



PREFACE TO THE FIRST EDITION 



This Practice of Obstetrics is founded upon fifteen years' work in maternity 
hospitals and in bedside and didactic teaching. 

The clinical and theoretical material collected from these sources has 
been rearranged, rewritten, and as far as possible compared with modern 
authorities. The aim of the present Practice of Obstetrics is to present the 
subject of midwifery from a practical and clinical standpoint, so that it will best 
facilitate the requirements of the student of medicine and of the active obstet- 
rician. To this end the simplest classification has, I believe, been adopted. I 
have omitted as unnecessary in such a work the elaborate section upon the 
anatomy of the female genital organs usually found in the works upon obstetrics, 
and have entered directly upon the physiology of these organs. The omission 
of the separate section upon anatomy is to avoid repetition, since the anatomy, 
histological and topographical, of the pelvis and its contents will be found 
in its appropriate place under the Parts on the Physiology of Pregnancy and 
Labor. I have divided the work into ten Parts, namely: I. The Physiology of 
the Female Genital Organs. II. Physiological Pregnancy. III. Pathological 
Pregnancy. IV. Physiological Labor. V. Pathological Labor. VI. Physio- 
logical Puerperium. VII. Pathological Puerperium. VIII. The Physiology of 
the Newly Born. IX. The Pathology of the Newly Born. X. ^Obstetric 
Surgery. 

This classification, elaborated and broadened from year to year, is practi- 
cally the same that I have followed during the above period in the two depart- 
ments of teaching. Several innovations will be found in this book. 

i. At the beginning of each Part the table of the contents of the part in 
question has been placed, and to further insure ease of reference each Part is 
subdivided into sections, each section in turn headed with a sub-table of its 
subject-matter. 

2. The subjects of asepsis and of pelvimetry, including cephalometry, are 
treated under The Examination of Pregnancy. I believe that this is the proper 
time and place for the student to be drilled in these subjects. 

3. The subject of Deformities and Monstrosities of the Fetus has been entered 
into more fully than usual under Antenatal Pathology, with 144 illustrations, 
including all of the common and most of the rarer monstrosities. 

4. The illustrations of the mechanism of labor and moulding of the fetal 
skull in vertex, bregma, brow, face, and pelvic presentation are mostly new, 
and are arranged as it has been my custom to teach these subjects. The illus- 
trations of cervical engagement of the presenting part were obtained by palpating 
with two fingers of the left hand, and at the same time sketching with a soft 
pencil in the right hand. Inspection of the cervical engagement by the aid 
of a perineal retractor and reflected light was also used, but this method was 
less satisfactory than palpation except in the case of face presentation. The 
illustrations of vulval engagement of the presenting parts are from flash-light 



PREFACE. 



photographs. Most of this work was done at the Emergency Hospital of 
Bellevue Hospital. The photographs of fetal skulls showing the result of 
head moulding are from skulls in the author's collection, which now numbers 
over one hundred. 

5. Short sections upon the medico-legal aspects of obstetrics, together with 
a brief study of Rape, the latter including an analysis of six hundred con- 
secutive examinations for evidences of the same, are placed under their appro- 
priate Part headings. 

6. I would especially call attention to the following subjects : (1) The relation 
of tuberculosis to pregnancy. (2) The teeth in pregnancy. (3) Antenatal path- 
ology. (4) Monstrosities, and deformities of the fetus. (5) Labor in elderly 
primiparce. (6) Prophylactic diet in fetal dystocia. (7) Prematurity and asphyxia 
of the newly born. (8) The diseases of the newly born. (9) Posture in ob- 
stetrics, and Obstetric Surgery. (10) The complete presentation of the subject 
of cephalometry. (11) New method for illustrating the mechanism of labor. 
(12) Pelvic Deformity. (13) Morbidity in the Puerperium. (14) An appendix 
on obstetric history keeping. 

Radiography in obstetrical practice is still in its infancy and the results as 
to fetography have been disappointing. On the other hand, Rontgen pho- 
tography of the maternal pelvis is a highly promising field, but as yet offers no 
practical advantages. 

As far as possible the subject of Embryology has been considered from the 
practical and clinical standpoint, and detail has been omitted as not suited to 
a work on practical obstetrics. Anatomical descriptions, except as necessary 
for the subjects of pregnancy and labor, have also been omitted. 

Much work had been expended upon the section on antenatal diseases of 
the fetus, before the appearance of Dr. Ballantyne's pioneer book upon Ante- 
natal Pathology. This work I have freely consulted in the revision of my 
manuscript. 

The 2200 confinement cases from which many of my statistics are drawn 
comprise 1000 cases from the New York Maternity Hospital and 1200 from the 
Mothers' and Babies' Hospital; 800 of the latter being dispensary or outdoor 
cases. The bound histories of these cases have been presented to the New 
York Academy of Medicine, and are there available for inspection. 

All unnecessary division into chapters has been discarded, and as far as 
possible italicizing has also been avoided. To replace the latter a system of 
paragraphing by means of display type in four series has been uniformly adopted 
throughout, supplemented by numerical divisions. It will be observed that as 
far as possible full-page illustrations have been avoided. My aim has been to 
insert the illustrations in the midst of the text itself so as to more readily catch 
the eye of the reader. To this end a rather wider page of printed matter than 
usual has been made use of and the illustrations are of moderate size. Many 
of the illustrations are new, collected during fifteen years of clinical work, and 
most of those taken from other sources have been redrawn. 

The illustrations, as will be noted, are not reproduced to a given scale, as I 
have found that clearness of detail is best obtained by the use of different scales 
of reproduction. All weights and measurements are given in English, with the 
metric system equivalents in parenthesis. 

To Simon Henry Gage, B.S., Professor of Histology and Embryology in the 
Cornell University, I am indebted for his critical revision of my manuscript on 
"The Phenomena Produced by Pregnancy within the Uterus." Also to Drs. 
Edward Preble and Emma E. Walker for much valuable assistance in the search 



PREFACE. xi 

through recent foreign obstetric literature and in the preparation of the index. 
The drawings for the illustrations were executed by Frank Stout, Howard J. 
Shannon, Frederick A. Fulton, and H. C. Lehmann. 

The author desires to thank most cordially the successive members of the 
House Staffs of the New York Maternity Hospital, and Emergency Hospitals, 
for valuable assistance in the preparation of the histories and records of 
obstetric cases; also Mr. Kenneth M. Blakiston, of the publishing firm of 
Messrs. P. Blakiston's Son & Co., for his unfailing courtesy in the many 
details of the preparation of the illustrations and the publication of the work. 

50 East 34TH Street, New York City, 
June ij, 1 90 j. 



TABLE OF CONTENTS 



PART I. 

PAGE 

THE PHYSIOLOGY OF THE FEMALE GENITAL ORGANS, 16 

This Part Contains 37 Illustrations. 

iCTION 

I. Ovulation, I 7 _I 9 

II. Menstruation, 20-27 

III. Insemination, 27 

IV. Impregnation, 27-30 

V. Rape, 30-37 

VI. Hygiene of the Sexual Functions 37~4 X 



PART II. 
PHYSIOLOGICAL PREGNANCY, 4 * 

This Part Contains 197 Illustrations. 

I. Phenomena Produced by Pregnancy within the Uterus, 43- 91 

II, Phenomena Produced by Pregnancy in the Maternal Organism, 91-122 

III. The Diagnosis of Pregnancy, 122-136 

IV. The Differential Diagnosis of Pregnancy, 136-142 

V. Feigned Pregnancy — Pseudocyesis, 142-143 

VI. Unconscious Pregnancy, 143 

VII. Multiple Pregnancy 144-148 

VIII. The Duration of Pregnancy, 148-150 

IX. Calculating the Date of Confinement, 150-152 

X. The Examination of Pregnancy, 152-191 

XI. The Hygiene and Management of Pregnancy 192-196 



PART III. 
PATHOLOGICAL PREGNANCY, i 97 

This Part Contains 278 Illustrations. 

I. Diseases of the Decidu^e, 199-208 

II. Diseases of the Chorion, 208-212 

III. Anomalies of the Amnion and Liquor Amnii, 212-218 

xiii 



xiv TABLE OF CONTEXTS. 

SECTION PAGE 

IV. Anomalies and Diseases of the Placenta, 219-252 

V. Anomalies of the Umbilical Cord, 252-257 

VI. Deformities and Monstrosities of the Fetus 257-285 

VII. Antenatal Diseases of the Fetus, 285-304 

VIII. Death of the Fetus, 304-306 

IX. Diseases of the Genital Organs, 307-324 

X. Toxemia of Pregnancy, 324-357 

XI. Diseases of the Urinary Tract 357-363 

XII. Diseases of the Alimentary Tract, 364-368 

XIII. Diseases of the Circulatory System, 368-37 1 

XIV. Diseases of the Respiratory System, 371-374 

XV. Diseases of the Nervous System, 3 75—378 

XVI. Infectious Diseases, 378-380 

XVII. Skin Diseases, 380-383 

XVIII. Diseases of the Osseous System, 3S3-3S4 

XIX. The Premature Interruption of Pregnancy, 3S5-404 

XX. Ectopic Gestation, 404-413 

XXI. Pregnancy in One Horn of a Uterus; Unicornis or Bicornis, 414-416 

XXII. Missed Labor, 416 

XXIII. Sudden Death During Pregnancy, 416 

XXIV. Injuries and Operations upon Pregnant Women, 416-417 

XXV. Pregnancy after Operations Involving the Genitals, 417 

XXVI. The Fever of Pregnancy, 418 

XXVII. The Metrorrhagia of Pregnancy, 418-420 



PART IV. 
PHYSIOLOGICAL LABOR, 421 

This Part Contains 133 Illustrations. 

I. The Passages, 423-458 

II. The Fetus, 458-478 

III. Expelling Forces, 478-482 

IV. Etiology of Labor, 482 

V. The Stages of Labor, 483-490 

VI. The Mechanism of Labor ' 490-498 

VII. The Duration of Labor, 498-499 

VIII. Live Birth, 499 

IX. Feigned Delivery, 499 

X. Unconscious Delivery, 500-501 

XI. Vertex Presentation, 501-514 

XII. Management of Labor, 514-54S 



PART V. 
PATHOLOGICAL LABOR, 550 

This Part Contains 278 Illustrations. 

DUE TO ABNORMAL CONDITIONS OF THE FETUS: FETAL DYSTOCIA, ... 551 

Fetal Dystocia from Faulty Attitude, 



3 3 



I. Excessive Flexion of the Head, Roederer's Obliquity 551—552 



TABLE OF CONTENTS. xv 

SECTION PAGE 

II. Bregma Presentation. Incomplete Flexion, 552—555 

v III. Brow Presentation, 555 - 56o 

IV. Face Presentation 560-570 

V. Presentation of Anterior Parietal Bone or Ear. Naegele's Obli- 

quity, 571 

VI. Presentation of Posterior Parietal Bone or Ear. Litzmann's 

Obliquity, 571-572 

VII. Prolapse of the Arms. Dorsal Displacement of the Arm, 572-574 

VIII. Prolapse of the Legs, 574 

IX. Prolapse of the Cord, 574~579 

Fetal Dystocia from Faulty Presentation, 579 

X. Pelvic Presentation, 579 _ 59° 

XL Shoulder Presentation, 590—597 

Fetal Dystocia from Faulty Position, 597 

XII. Persistent Occipito-posterior Position, 597-603 

XIII. Persistent Mento-posterior Position, 603-605 

XIV. Transverse Engagement of Head in Inlet in Deformed Pelvis, 605-608 

XV. Transverse Position of Head at Outlet, 608-609 

Fetal Dystocia from General Fetal Conditions, 610 

XVI. Multiple Birth, 610-613 

XVII. Multiple or Compound Presentations, 613-614 

XVIII. Excessively Long Cord, 614 

XIX. Short Cord, 614-615 

XX. Rupture of the Cord 615-616 

XXI. Decapitation of the Fetus, 616 

XXII. Avulsion of Fetal Extremities, 616 

XXIII. Malformations, Deformities, and Anomalies Producing Dystocia,. . .616-621 

XXIV. Fetal Rigor Mortis, 622 

DUE TO ABNORMAL CONDITIONS OF THE MOTHER. MATERNAL DYS- 
TOCIA, 622 

Maternal Dystocia from the Forces, 623 

I. Precipitate Labor, 623-625 

. II. Protracted or Retarded Labor: Uterine and Abdominal Inertia, . 625-630 
Maternal Dystocia in the Parturient Tract and Adnexa, 630 

III. Retention of Placenta and Membranes, 630-633 

IV. Post-partum Hemorrhage 633-641 

V. Rupture of the Uterus, 641-647 

VI. Inversion of the Uterus, 647-649 

VII. Excessive Right Lateral Obliquity of the Uterus, 649 

VIII. Rupture of Cervix, Vagina, Rectum, Perineum, 649-665 

IX. Labor After Anterior Fixation or Suspension of the Uterus, 657-659 

.Maternal Dystocia from Obstructed Labor, 659 

X. Uterine, Ovarian, Renal, Peritoneal Tumors, 659-661 

XI. Anomalies of the Membranes 662 

XII. Rigidity of the External and Internal Os. Trismus Uteri, 663-665 

XIII. Deviation or Malposition of the Os, 665-666 

XIV. Occlusion of the External Os 666-667 

XV. Cancer of the Uterus, 667-668 

XVI. Rigidity and Atresia of the Vagina and Vulva 668-670 

XVII. Vaginal and Vulval Thrombosis and (Edema, 670-671 

XVIII. Distended Bladder and Rectum, Cystocele, Rectocele, Vesical 

Calculus 671-672 

XIX. Fractures of the Pelvis, . 673 

XX. Diastasis of the Pelvic Joints, 673 

XXI. Pelvic Deformity 673-724 



xvi TABLE OF CONTENTS. 

SECTION PAGE 

Maternal Dystocia from General Maternal Conditions, 724 

XXII. Labor in Elderly Primipar^e, 724-726 

XXIII. Intestinal Hernia, 726 

XXIV. Cardiac and Pulmonary Disease, 726 

XXV. Cerebral and Spinal Disease, 726 

XXVI. Digestive Disturbances, 728 

XXVII. Sudden Death, 728 

XXVIII. Postmortem Delivery, 730 

XXIX. The Metrorrhagia of Labor 730 



PART VI. 
PHYSIOLOGICAL PUERPERIUM. THE PUERPERAL WOMAN, 732 

This Part Contains 18 Illustrations. 

I. General Phenomena, 733—737 

II. Local Phenomena 73 7~747 

III. Diagnosis of the Puerperium, 747-748 

IV. Management of the Puerperium, 748-75S 



PART VII. 
PATHOLOGICAL PUERPERIUM, 760 

This Part Contains 52 Illustrations. 

I. Puerperal Hemorrhages, 761-764 

II. Intestinal Anomalies, 764 

III. Urinary Anomalies, 765-767 

IV. Anomalies of the Genital Tract, 767-769 

V. Anomalies of the Pelvic Articulations, 769 

VI. Diastasis of the Abdominal Muscles, 769-770 

VII. Fever in the Puerperium, 770-825 

VIII. Anomalies of the Breasts, 825-826 

IX. Anomalies of the Milk Secretion, 826-827 

X. Diseases of the Breasts, 827-834 

XI. Blood Conditions, .834-835 

XII. Diseases of the Nervous System, 835-839 

XIII. Skin Diseases, 839 

XIV. General Diseases, 839 

XV. Sudden Death 839-S42 



PART VIII. 



THE PHYSIOLOGY OF THE NEWLY BORN, s 44 

This Part Contains 15 Illustrations. 

I. General Phenomena, 845-S5 1 

II. Hygiene and Management of the Newly Born, 851-862 



TABLE OF CONTENTS. xvii 
PART IX. 

PAGE 

THE PATHOLOGY OF THE NEWLY BORN, ... 86 4 

This Part Contains 36 Illustrations. 

SECTION 

I. Pathology due to Interrupted Pregnancy. Prematurity, 866-872 

II. Affections of Antenatal Origin which Extend into Extrauterine 

Life, 873-878 

III. Affections which Originate Intra partum, 878-903 

IV. Diseases Incident to Change of Environment, 903-906 

V. .Diseases due to Bacteria and Fungi, 906-914 

VI. Diseases of Unknown Nature, 914-919 

VII. General Post-partum Conditions, 919-925 



PART X. 
OBSTETRIC SURGERY, 926 

This Part Contains 214 Illustrations. 

(A) INTRODUCTION, 927 

I. Preparations for Operation, 928-929 

IL. Decinormal Saline Solution Injections, 929-933 

III. Anesthesia in Obstetrics, 933-936 

IV. Posture in Obstetrics, 936-947 

V. Vaginal Examination, 947 

VI. Digital Exploration of the Uterus, 948 

VII. Vulval Douche, 949 

VIII. Vaginal Douche, . 949-950 

IX. Intrauterine Douche, 950-952 

X. Vaginal Tampon, 95 2 ~953 

XI. Uterine Tampon 953—955 

XII. Passing the Catheter, 955 

(B) OPERATIONS PREPARATORY TO DELIVERY, 955 

I. Artificial Rupture of the Membranes, 955 - 956 

II. Induction of Abortion and Premature Labor, 956-963 

III. Manual Dilatation of the Cervix, 963-969 

IV. Instrumental Dilatation of the Cervix, 969-974 

V. Manual and Instrumental Dilatation of the Vagina and Vulva, . . . 974-975 

VI. Incisions of the Cervix, Vagina, and Vulva, 975-980 

VII. Correction of Faulty Postures, Malpositions, and Malpresenta- 

TIONS 980-983 

VIII. Vectis 9S3 

IX. Fillet : . 983-984 

X. Reposition of Prolapsed Small Parts, Foot, and Cord, 984-987 

XI. Version, 987-1005 

XII. Pelviotomy, 1005 

XIII. Symphyseotomy, • 1006-1010 

XIV. Embryotomy in General, 1010-1012 

XV. Perforation, 1013-1015 

XVI. Rachidotomy, 1015 

XVII. Cranioclasm, 10 16-1020 

XVIII. Cephalotripsy 102 1-1025 



xviii TABLE OF CONTENTS. 

SECTION PAGE 

XIX. Decapitation, 1025-1030 

XX. Evisceration, 1030-103 1 

XXI. Amputation of Extremities, 103 1 

XXII. Cleidotomy 103 1-1032 

XXIII. Spondylotomy, 1033 

(C) OPERATIONS FOR DELIVERY, 1033 

I. Expression of the Fetus, Expressio Fcetus, 1033-1034 

II. Forcible Delivery, Accouchement Force 1034-1035 

III. Manual Extraction of the Fore-coming Head, 1036 

IV. Shoulder Extraction in Head-first Labors, 1037-1038 

V. Breech Extraction, 1038-1044 

VI. Extraction of the After-coming Head 1044-1054 

VII. Forceps, 1054-1078 

VIII. Sling or Soft Fillet, 1078-108 1 

IX. Blunt Hook 1081 

X. Crochet • 1082 

XI. Extraction of the Fetus Mutilated by Embryotomy, 1082 

XII. Cesarean Section 1082-1088 

XIII. Vaginal Cesarean Section, 108S-10S9 

XIV. PORRO-C^ESAREAN SECTION, I089-IO9O 

XV. Post-mortem Cesarean Section, 1090 

XVI. Celiotomy for Ectopic Gestation, 1090-109 1 

XVII. Delivery of Placenta and Membranes, 1091-1097 

(D) OPERATIONS FOR THE CORRECTION OF INJURIES, _ 1097 

I. Celiotomy for Rupture of the Uterus, 1097 

II. Celiotomy for Sepsis of the Uterus, 1098 

III. Repair of Injuries to Cervix, Vagina, Rectum, Perineum, 1098-1 103 



APPENDIX. 

This Contains 10 Illustrations. 

Private History Records, 1 105-1 108 

Institutional Records, 1109-1 112 



INDEX, 1 1 13 



PART ONE. 

The Physiology of the Female Genital Organs* 



I. OVULATION.— Definition; Origin of the Ova; Causes of Rupture of the 
Graafian Follicle ; Mechanism of the Conveyance of the Ovum to the Tubes 
and Uterus ; Corpus Luteum ; Retrograde Changes in the Corpus Luteum ; 
Obliteration of Follicles which do not Rupture. 

II. MENSTRUATION. — Synonyms; Definition; Puberty; Phenomena; Changes 
in the Endometrium during Menstruation ; Time of Occurrence ; Conditions 
Influencing Menstruation; The Menstrual Cycle; Menstruation — Tem- 
porary, Intermittent, and Periodic; Duration; Quantity of Blood Lost; 
Composition of the Menstrual Blood; Modifications and Anomalies; Rela= 
tion between Menstruation and Ovulation ; The Menopause. 

III. INSEMINATION.— Definition; Phenomena. 

IV. IMPREGNATION. — Synonyms ; Definition; The Semen; The Spermatozoa; 

Ascent of the Spermatozoa ; Place of Meeting of Spermatozoa and Ovum ; 
Relation between Impregnation and Menstruation; Unconscious Impreg= 
nation. 

V. RAPE. — Definition; Law of Rape; Rape on Females after Puberty; Condi= 
tions Simulating Defloration; Rape upon Children and Infants; Rape by 
Boys and Children ; Rape on the Dead ; Statistics of 600 Consecutive Exam= 
inations for Evidences of Rape. 

VI. HYGIENE OF THE SEXUAL FUNCTIONS.— Heredity ; Education; Mode 
of Life ; Dress ; Sexual Life ; Prevention of Conception ; Child=birth ; Climac= 
teric; Cancer; Family Physician. 



I. OVULATION. 

Definition.^This term includes the formation, growth, and expulsion of the 
mature ovum from the ovary. The chief function of the ovary is accomplished in 
this process. It takes place spontaneously in all viviparous animals. 

Origin of the Ova. — The ova originate from certain cells which are derived 
from the ingrowth of the germinal epithelium that surrounds the young ovary, 
and which are gradually differentiated into the female generative elements. 
This occurs very early; in fact, the formation of the Graafian follicles is nearly 
completed during the antenatal period. After birth the formation of new cells 
is much restricted, and at the end of the second year is supposed to cease entirely. 
The ovaries of a child of two years are estimated to contain about 70,000 Graafian 
follicles. The greater number of ova never arrive at maturity. Before puberty 
some of these immature ova undoubtedly develop to a certain point, but it is not 
until the establishment of menstruation that the normally complete maturation 
of the follicles with their ova takes place. With the advent of puberty the sur- 
face of the ovary becomes covered with small projections. These prominences 
are the Graafian follicles, which are distended by the liquid within them. They 
approach the ovarian periphery, cause a thinning of the tunica albuginea, and 
give rise to the vesicles before mentioned. Gradually the blood-vessels and 
lymphatics disappear, and at a certain point the covering of the follicles becomes 
thin and translucent, usually at the place called the macula, or stigma folliculi. 
When the follicle reaches maturity it bursts, discharging its contents, which 
consist of an ovum, the liquor folliculi, and a few cells of the discus proligerus. 
This change takes place periodically, now in one, now in more than one follicle, 
during the entire child-bearing period. Several follicles in different stages of 
development may be found at the same time. The particular follicle that is 
nearing maturity becomes congested and some of the enlarged blood-vessels 
burst into its cavity, thus increasing the distention and the tendency to rupture. 
When mature, the follicle is, on account of the escaped blood, of a bright red 
color. As to the time of rupture of the follicle, whether it occurs before or after 
menstruation, is a question not yet definitely settled. In order that the ovule 
may escape, not only must the layers of the follicle be lacerated but also all of 
the structures covering it. 

Causes of Rupture of the Graafian Follicle. — Follicular rupture is produced by 
a combination of several factors : (1) By the pressure of the liquor folliculi, which 
causes thinning and absorption of the theca folliculi, the follicular wall having 
been weakened by fatty degeneration of the tissues. (2) By the proliferation of 
the lutein cells, causing the tension of the liquor to be raised. (3) By the swell- 
ing of the ovary at every menstrual period. (4) By the contraction of the 
ovarian muscular fibers. (5) Ovulation is a periodic process, and in nearly all 
mammals, except man, it occurs only at certain seasons of the year, so that 
the young are born at a time when food suitable for the parent is most abundant. 
(6) Sexual congress may influence the discharge of the ovum, probably only 
hastening the normal process. (7) The sympathetic nervous system also in 
some way affects the process. 

2 17 



18 PHYSIOLOGY OF THE FEMALE GENITAL ORGANS. 

Mechanism of the Conveyance of the Ovum to the Tubes and Uterus. — The 

oldest theory of this conveyance, that held by Rouget, was that the fimbriated 
extremity of the tube became erectile and, aided by muscular contraction, 
grasped the ovary. The existence of a peculiar erectility in the Fallopian 
tubes has, however, been disproved, as experiments show that it possesses none 
of the characteristics of erectile tissue. Galvanization of the tubes shortly after 
death produces only a vermicular action which has no effect on the position of 
the fimbriae. Kehrer's theory was that the ova were ejaculated from the follicle 
into the tube, a view that has been upheld by few. The most probable theory is 
that of Henle, that the ova are carried along in the serum by currents generated 
by the ciliated epithelium which covers the fimbriae of the tubes. This ciliary 
motion causes a current in Douglas' cul-de-sac. This action has been demon- 
strated by Pinner, who injected powdered insoluble coloring-matter into the 
abdominal cavity of a rabbit. Particles were found after death in the uterus and 
vagina. The same phenomenon was observed by Jani (Weigert's laboratory) in 
regard to tubercle bacilli. Lodi injected the eggs of a tapeworm into the peri- 
toneal cavity of rabbits and recovered them in the tubes and uterus. In the 
lower animals the majority of the ova pass into the tube, but in man it would 
seem that the greater part are thrown into the abdominal cavity. It is usually 
stated that it takes eight days for the ova to reach the uterus. In a certain 
number of cases there is a migration of ova, which pass across the abdominal 
cavity and come down the opposite tube. This is called external migration. 
Pathological conditions afford proof of this fact. There are two classes of such 
cases: (i) With normal tubes. If we find a corpus luteum in the right ovary 
and the right tube converted into a hydrosalpinx, the inference of external migra- 
tion may be drawn. Also in tubal pregnancy: given an occluded right tube 
with a corpus luteum in the right ovary, and a pregnancy in the left tube with no 
corpus luteum in the left ovary, and we must draw the same inference. (2) In 
the case of bicornate uterus a corpus luteum may be found in one ovary and 
pregnancy in the other side of the uterus. Kussmaul was the first to advocate 
this view of external migration. Leopold and others have experimented by 
removing in an animal a tube and the opposite ovary. Later, if the animal 
became pregnant the proof of external migration was positive. The author has 
repeatedly demonstrated this external migration of the ovum by operating upon 
rabbits in the Loomis laboratory. Older writers declared that there was internal 
migration causing tubal pregnancy in the opposite tube, the ovum having passed 
through the uterus. This statement cannot be denied, neither can it be proved. 
Hence we see that external migration does take place, whereas the occurrence 
of internal, though possible, has not been proved. 

Corpus Luteum. — After the follicle has ruptured and the ovum has been cast 
off, the corpus luteum is formed. As has been said, previous to rupture there has 
occurred a fatty degeneration of the cells of the membrana granulosa and of the 
discus proligerus. There is a certain amount of hemorrhage within the follicle, the 
walls collapse, and this is the first stage of the corpus luteum. The hematin of the 
extravasated blood gives rise to the "yellow" color. The cells of the internal 
layer of the theca folliculi rapidly proliferate, forming festoons which project into 
the blood-clot contained in the cavity of the follicle (Fig. 1). This yellow layer is 
quite thick, being about one-half the thickness of the whole corpus, which meas- 
ures half an inch (1.25 cm.). These cells are lutein cells. The stroma of the ovary 
also sends ingrowths into this mass. The blood-clot organizes, the walls contract, 
and finally a small, irregular cavity is left. This is at last obliterated by the 
meeting of the walls, and merely a cleft remains. A corpus luteum is formed 



OVULATION. 19 

with every bursting of a follicle. When fertilization of the ovum occurs, the 
corpus luteum becomes larger. The old terminology recognizes a corpus luteum 
verum and a corpus luteum spurium. The corpus luteum of pregnancy meas- 
ures about four-fifths to one inch (2 to 2.5 cm.) in comparison with the ordinary 
corpus luteum, which measures about f inch (1.5 cm.). For some time the idea 
obtained that there was a marked difference between the corpus luteum verum 
and the corpus luteum spurium; it has, however, been shown that the only differ- 
ence is that of size, due to the greater blood-supply during pregnancy. There 
has been endless discussion about the corpus luteum, the principal point of dis- 
pute being the hyaline change. 

Retrograde Changes in the Corpus Luteum. — After the formation of the corpus 
luteum the yellow layer is converted into a hyaline mass which is penetrated by a 



Tunica externa 
Tunica interna 



Stratum granulo- 
sum {follicular 
epithelium) 




Cumulus ovigerus 

Ovum with zona 
pellucida, germi- 
nal vesicle, and 
germinal spot 

Fig. 1. — Section of a Large Graafian Follicle of a Child Eight Years Old. X 90. 
The clear space within the follicle contains the liquor folliculi. — (Stohr.) 

few bands of ovarian stroma. Finally a thin layer of connective tissue is the only 
representative of the blood-clot, and this stage is known as the corpus fibrosum 
or corpus albicans. But still further changes must go on, for only a few of these 
bodies are to be found in an ovary. The minor details of the change are not well 
known. The ovarian stroma prolongations increase, while the hyaline material 
diminishes and assumes bizarre forms. At last there may be only a dot of con- 
nective tissue remaining. Only twenty or thirty follicles rupture in a year and 
many ova disappear. Many follicles never rupture at all. 

Obliteration of Follicles which do not Rupture. — The ovum may assume signs 
of maturity, fatty degeneration takes place in the membrana granulosa, the 
whole mass dissolves in the liquor folliculi, and the fluid finally disappears and 
the walls collapse. There is absence of blood-clot. The follicle is surrounded by 
a thin hyaline stratum formed from the inner layer of the theca folliculi. 



20 



PHYSIOLOGY OF THE FEMALE GENITAL ORGANS. 



II. MENSTRUATION. 

Synonyms. — Menses; Menstrual flow; Menstrual flux; Flow; Catamenia. 

Definition. — By this term is meant the monthly hemorrhage which takes 
place in the uterus during the child-bearing period of the normal woman, except 
during pregnancy and lactation, when it is nearly always suspended. 

Puberty. — The first occurrence of menstruation with the accompanying 
changes marks the stage of sexual maturity at which, in the female, fecundation 
becomes possible. The signs are: The growth of hair on the pubes and on other 
parts of the body; the enlargement of the breasts; the increased grace of the 
general contour of the body; the establishment of ovulation and menstruation; 
the full development of the pelvis ; the growth of the sexual sense ; alteration in 








Fig. 2. — Uterus and Adnexa showing Coincident Menstruation and Ovulation. 
Suicidal death from morphine on second day of menstruation. — (Author's specimen.) 



the mental qualities, the girl becoming more retiring. The menstrual function 
is not generally established at once, but for the first few months there may be only 
premonitory symptoms of a vague and uncomfortable nature. There may soon 
occur a slight discharge of mucus tinged with blood, and later the regular menses 
will be established. 

Phenomena. — (i) The General Phenomena consist of pains in various parts 
of the body, chilliness, heat flashes, and hysterical symptoms. The reflex 
nervous system is always at its maximum point of irritability and there is often 
depression with drowsiness. There are general discomfort, weariness, and a 
marked distaste for active exercise. Dark circles appear under the eyes, the 
breasts swell and become painful, and a sense of fulness and oppression is felt in 
the head (Fig. 6). There are often considerable changes in the general nutritive 
processes and the excretion of urea by the kidneys is lessened. (2) The Local 
Phenomena are those of pelvic congestion. Rupture of an ovisac occurs, the 



MENSTRUATION. 



21 



Epithelium 



- Gland-tubule 









Mucosa 



uterus becomes much congested, the cervix softens and is of a bluish color with 
relaxation of the external and of the internal os. The uterine mucous membrane 
is also swollen, congested, and raised into folds which give the surface an irregular 
appearance (Fig. 2); abundant secretion pours from the glands, and, at least in 
some cases, the epithelium desquamates, and the capillaries losing their support, 
their walls undergo fatty degeneration, burst, and discharge the blood (Fig. 4). 
The tubes are also congested and thickened, and blood sometimes escapes into 
them. The vagina becomes darker in color, gland secretion is abundant, and the 
temperature is slightly elevated, often by i° F. (0.5 C.) (Fig. 7). The whole 
vulva is swollen and tense and pruritus may occur (herpes menstrualis) . 

Changes in the Endometrium during Menstruation. — Various views have been 
held as to the changes in the uterus at this time. The prevailing view, upheld 
by Leopold, Wyder, Minot, 
Kundrat, and Engelmann, 
is that a certain amount of 
the mucosa, though small, 
is cast off. Engelmann 
and Kundrat showed that 
there is fatty degeneration 
of the walls of the blood- 
vessels which permits the 
outflow of blood, and they 
believe this to be the 
primary change during men- 
struation. Leopold and 
Wyder regard it as secon- 
dary to malnutrition, which 
seems the more rational 
view. Leopold believes that 
the flow arises from diape- 
desis of the blood-corpus- 
cles, while Gebhard observe 
that this process would 
cause a "sub-epithelial he- 
matoma," followed by an 
oozing and escape of blood. 
The amount of blood is 
comparatively small and 
does not really constitute 
a true hemorrhage. The 

flow is preceded by alterations in the glands, which become hypertrophied and 
present a zigzag appearance on cross-section, while the cells in the lower part of 
the glandular structure may become larger and resemble epithelial cells. The 
connective-tissue cells also undergo hypertrophy (Figs. 4 and 3). 

Time of Occurrence. — As has been stated, the establishment of puberty ushers 
in the process of menstruation. The accompanying physical changes give evi- 
dence of the capacity for conception and child-bearing now assumed by the 
woman. In temperate climates the average age for the beginning of menstrua- 
tion is the fifteenth year. There are, however, many exceptions to this rule 
within normal limits, as it is not so very uncommon to observe the beginning of 
this process at the tenth or eleventh year, or its delay to the eighteenth or twen- 
tieth. The average age in India is said to be the ninth year, while in Iceland it 



Fig. 3. — Mucous Membrane of the Resting Uterus 
of a Young Woman. X 35. — {After Bohm and von 
Davidoff.) 



22 



PHYSIOLOGY OF THE FEMALE GENITAL ORGANS. 



is given as the sixteenth year. There are instances of curiously abnormal cases. 
Menstruation has been recorded in very young infants. Montanaier cites the case 
of a child less than six months old, very large and with well- developed breasts. 
Other cases at the age of one year have been reported. (See Part IX.) Ahlfeld 
reports that of Anna Mummenthalen, who menstruated from her second to her 
fifty-second year. In her eighth year she became pregnant, and gave birth to a 
child in her ninth year. D'Outrepont reports a birth in the ninth year of age 
without the establishment of menstruation. Ahlfeld reports one of his own 
cases, that of a child of thirteen, who had an ectopic pregnancy ; also that 



* $e •'% * ... , 

Disintegrated surface ~7T.stf& '/$'' : '\M 

:"Sf6tr 

Blood-vessels "^fro^r^V- 



Excretory duct 



Glandular lumen 




Superficial epithelium 



'"fe^^x^"" Disintegrated surface 
l@^*t~ ) — Depression in mucosa 



Excretory duct 



Blood-vessel 



-M--^g jf ;$ WMwWW^. A 



Blood-vessel 




Muscularis 



Fig. 4. — Mucous Membrane of a Virgin Uterus during the First Day of Menstrua- 
tion. X 30. — (Schafer.) 

of a child of fourteen years and three months who gave birth to an infant 
21 inches (53 cm.) in length, and weighing 11 pounds (3620 gm.). In support 
of the fact that pregnancy can take place in complete absence of menstruation, 
the same author reports the case of a woman who had never menstruated but 
who bore a child in her thirty-second year. He also cites the case of a woman 
who had had eight children but who had never menstruated. Cases in which 
births occurred after the cessation of menstruation are also noted. Kennedy * 
cites the case of a woman sixty-two years of age who gave birth to a child. This 
* " Edinburgh Medical Journal," 1882, vol. xxvn, p. 1085. 



MENSTRUATION. 23 

patient had, in all, borne twenty-two children. Menstruation had always been 
regular. La Motte reported a case in which a woman gave birth to a child seven 
years after the menopause. The time of cessation normally occurs about the 
forty-fifth year. 

Conditions Influencing Menstruation. — Menstruation is influenced by (i) 
race; (2) mode of life; (3) climate; (4) heredity; and (5) genital sense. Some 
authors lay considerable stress on the influence of race. It is said that English girls 
in Calcutta menstruate no earlier than in England, although subjected to the same 
climatic influences as the Hindoos, 1 or 2 per cent, of whom menstruate as early 
as the ninth year, while 25 per cent, menstruate at twelve years of age. The 
children of the superior classes, being of a higher nervous organization, are apt to 
menstruate earlier. Their manner of life is more luxurious and mental stimulation 
is premature, as shown in the earlier period of menstruation. As to the influence 
of climate, it has no doubt been exaggerated, although the general rule holds that 
menstruation occurs somewhat earlier in the tropical than in the arctic regions. 
Premature or late sexual development is often noticed as a family trait. Sexual 
excitement is thought to influence the advent of menstruation, and Clay * has 
noted this excitement among the hard-working factory girls of Manchester, 
where, in the nature of the work, there is a promiscuous mixing of sexes. In the 
case of pregnancy, menstruation is nearly always suspended during the whole 
period of gestation, recurring from six to eight weeks after the birth of the 
child. Exceptions to the rule of suspended menstruation in pregnancy 
occur now and then during the early months, and are explained by the fact that 
the uterine cavity is not obliterated by the junction of the decidua reflexa and 
the mucous membrane of the uterus, or the decidua vera, till the close of the fifth 
month. In case the menses continue throughout pregnancy, — a very rare con- 
dition indeed, — there is probably an abnormal and incomplete fusion of the 
decidual. Some cases of women who menstruate only during pregnancy have 
been reported. Such reports should be carefully sifted, as these cases probably 
depend, without exception, on pathological conditions of the cervical canal. If 
the ovule is impregnated, menstruation is prevented. Some advocate the theory 
of a "missed" conception; i. e., that when conception does not occur at the time 
of ovulation, the uterus gets rid of the excess of material that has accumulated in 
the preparation for conception. Naegele f held just the opposite view — that 
menstruation regenerates the capacity for conception which had failed by degrees 
during the intermenstrual period. The relation between menstruation and the 
"heat" of lower animals is a very interesting study. The most satisfactory 
theory appears to be that menstruation is caused by a central nervous influence 
reflected through the sympathetic nervous system to the ovaries and uterus. 

The Menstrual Cycle. — The entire menstrual cycle comprises four stages 
(Marshall), and extends, as a rule, over twenty-eight days: (1) The preparatory 
or constructive stage consists in making ready for the reception of the ovum. 
This preparation, according to Marshall, is probably made for the ovum which is 
discharged at the preceding period, for it is probable that a week is consumed in 
the migration of the ovum from the ovary to the uterus. When pregnancy does 
not occur, this stage is followed by degenerative changes. (2) The destructive 
stage comprises all the ordinary phenomena of menstruation. It lasts about five 
days, varying, however, according to individual peculiarities. (3) The re- 
parative stage is occupied with the regeneration of the destroyed parts of the 
uterine tissue — the focus of new growth being the unharmed deeper tissues still 

* "Brit. Record of Obstet. Med.," vol. 1. 

t " Erf ahrungen und Abhandlungen," Mannheim, 1812. 



24 PHYSIOLOGY OF THE FEMALE GENITAL ORGANS. 

existing. This process takes place in from three to four days. (4) The quies- 
cent stage comprises the remaining twelve or fourteen days of the whole cycle 
and just precedes the beginning of the next period. 

Menstruation is Temporary, Intermittent, and Periodic. — It is temporary be- 
cause it exists only during the sexual life of the woman, asserting itself at puberty 
and declining at the menopause till it ceases altogether. It is intermittent 
because it comes and goes, and periodic because the series of phenomena repre- 
senting this physiological process reproduce themselves at intervals of usually 
one month, being the result of the hyperemia which occurs in the whole genital 
system of the woman — ovary, tubes, uterus, and broad ligaments. Periodicity 
is variable, but twenty-eight days is considered the normal period. Two sisters 
are mentioned in whom menstruation occurred only two or three times a year 
(Joulin). 

Duration. — The duration of menstruation averages five days, but varies from 
three to seven. Some cases are known in which menstruation lasts only a few 
hours, others in which it lasts many days. 

Quantity of Blood Lost.^-The total amount lost varies normally from five to 
ten ounces. The amount, even if rather large, need not be considered abnormal 
unless the general health suffers. High living, rich diet, and, indeed, anything 
that abnormally stimulates mind and body, will tend to increase the flow. Con- 
sequently city-bred girls and those of the higher classes have a greater flow than 
the hard- worked women of the laboring classes. It is also greater in warm 
climates than in cold, and English women in India menstruate profusely, while 
on their return to England there is marked decrease of the flow. The same fact 
has been noted in American women moving from the Southern States to the Lake 
region. It appears that women sometimes menstruate more profusely in summer 
• than in winter. The daily loss is not the same during the period. It is slight at 
first, as a rule; reaches the maximum on the third day, and then gradually de- 
creases. At the last it often ceases for a few hours and then returns. Emotion 
or excitement of any kind is very apt to bring it on. 

Composition of the Menstrual Blood. — The discharge is made up of water, red 
and white blood-corpuscles, mucus-corpuscles, abundant epithelial cells from the 
uterus and vagina, and rarely strips of uterine mucosa. Virchow believes that 
some of the epithelium comes from the interior of the uterine glands. The direct 
discharge from the uterus consists of pure blood, and if it is collected by the 
speculum it will coagulate. The fact that ordinary menstrual blood does not 
coagulate has caused much speculation. Mandl has given the true explanation 
by showing that small quantities of mucus or pus will keep fibrin in solution, and 
that the former is always found in the secretions from the cervix and vagina and 
mingles with the blood in its passage from the uterus to the external world. 
However, in case of excessive flow there will not be sufficient mucus to act on all 
the fibrin. The color is generally dark at first, while later it becomes paler. 
Women in poor health often have a very pale discharge. The amount of inter- 
mingled mucus doubtless has much to do with the differences in color. The reac- 
tion is alkaline. There is always a faint odor to menstrual blood which is char- 
acteristic. It has been likened to that of marigolds. It is probably due either to 
decomposing mucus or to the mixture of excretion from the vulvar sebaceous 
glands. This peculiarity has been noted from the earliest times, and even now 
in England on many farms the old prejudice of the deleterious effects of menstrual 
blood is seen in the custom of not allowing menstruating women to attend to the 
making of butter, preserves, cheese, etc. The influence of menstruation on the 
general health is very apparent. 



MENSTRUATION. 25 

Modifications and Anomalies of Menstruation. — At times menstruation occurs 

through the skin of the mammas. This is probably due to their intimate sympa- 
thetic connection with the generative organs. Bleeding may also take place from 
the surface of an ulcer or from hemorrhoids. All of these locations are such as to 
give easy external escape to the blood. In other cases the bleeding occurs from the 
nose; or there may be vomiting of blood or bleeding from the lungs. Cutaneous 
hemorrhage may take place. Vicarious menstruation is generally a sign of ill 
health and is usually seen in young women of highly nervous organization. It 
may begin at puberty and continue throughout the entire sexual life. Its occur- 
rence is periodic, corresponding with the menstrual nisus, although the amount 
of blood is generally considerably less than that lost in normal menses. We find 
also such abnormalities as menorrhagia, dysmenorrhea, and retention of menses 
from obliteration of the neck of the uterus or the vaginal orifice. Another modi- 
fication consists in the suppression of menstruation from pregnancy, from lacta- 
tion, or from emotion. 

Relation between Menstruation and Ovulation. — This relation is not entirely 
clear. Menstruation is not necessary to child-bearing, but there is a marked 
connection between ovulation and menstruation. Various theories are ad- 
vanced: by Pfliiger, that the presence of the ripe follicle causes a reflex action 
which brings on menstruation; by Strassmann, that menstruation is due to 
pressure changes in the ovary. To prove this he injected a sterile fluid into the 
ovary and found the animal went in "heat" as a result. It has also been 
observed that on the second or third day after ovariotomy the patient often 
undergoes a pseudo-menstruation, probably caused by the pressure of the 
ligatures ; also that menstruation may continue after ovariotomy. Some have 
tried to explain this by saying that a portion of the ovary had been left behind 
or that the discharge had come from some pathological condition not noticed at 
the time. These cases, however, are too numerous to be explained on the sup- 
position of a mistake. Leopold showed that ova mature at all times, both before 
puberty and after the menopause, and this was observed by others. Lowenthal 
thought that menstruation depended upon non-fertilization of the ovum; that 
is, was a primitive abortion. Reichert, His, and other embryologists have also 
worked on this subject. Variations of three weeks have been noticed in the 
time of delivery corresponding to fertilization just before or just after menstru- 
ation. Young girls have also become pregnant before menstruation began, 
and ruptured follicles have sometimes been found in the ovary in the inter- 
menstrual period. Pregnancy seldom occurs during lactation, though men- 
struation begins much sooner than the end of lactation. Lawson Tait 
believed that there are nerves from the tubes to the sympathetic system, and 
these he called menstruating nerves. All of these facts make the relationship 
of menstruation to ovulation somewhat obscure. The following conclusions, 
however, may be safely drawn: Ovulation and menstruation occur about the 
same time, although ovulation often follows menstruation and may occur be- 
tween the menses. The ovarian changes which precede ovulation, by producing 
ovarian tension, reflexly excite the uterus and cause menstruation. These 
changes are nearly or quite complete before the bursting of the Graafian follicle. 
The time of labor cannot be accurately estimated, and rules for avoiding concep- 
tion are very uncertain. Both ovulation and menstruation are under some ner- 
vous control, yet either process may occur independently. Conception is more 
apt to result from a coitus just after a menstrual flow than at any other time. 
Three theories have been advanced as to these relations: (i) Ovulation deter- 
mines menstruation; (2) menstrual congestion favors ovulation, since there occur 



26 



PHYSIOLOGY OF THE FEMALE GENITAL ORGANS. 



simultaneously congestion of the ovary and uterus; (3) menstruation and ovu- 
lation are interdependent. 

The Menopause. — The climacteric or change of life varies as widely as does 
the establishment of menstruation, although the average age is between forty and 
fifty years. Cases of women menstruating till the eightieth or ninetieth year, 
which have been reported, must be regarded as exceptional and as having no 
bearing on the general rule. The great majority of women cease to menstruate 
in the forty-sixth year; most cases of prolonged menstruation are dependent on 
pathological conditions — organic disease of some kind, malignant or otherwise. 
Cases in which menstruation ceased between the ages of thirty and forty years 
are noted, certain instances being recorded as early as the twenty-fifth year. 
It is the generally received opinion that women who begin to menstruate early 



UNE OF'SECTfOM 



Crural nerve 
Psoas muscle 
Iliac muscle 
Crural artery {injected) 
Infundibulo-pelvic liga- 
ment 
Opening of right tube 
Obturator artery 
Origin of uterine and 
vesicular arts. 
Broad ligament 
Right ovary 
Mesenterium tubes 

Middle hemorrhoidal 
artery 




Right ureter -~ 

Right tube ? 

Common pudic art. - 

Transverse sec. of round lig. ' 

Gluteal muscle ■"" 

Transverse sec. of rectum ' 



y 



Rectum 
Crural nerve 
Crural artery {injectet 
Med. and small gluteal 

muscle 
Obturator nerve 
Obtmator artery 
Origin of uterine and 

vesicular arts. 
Ligament, latum coven 
Left ureter. [left ov\ 

Left broad lig. 
Ischial nerve 

Middle hemorrhoidal 

artery 
Left tube 

Ant. border of pyriform muscle 

Transverse sec. of round lig. 

Common pudic art. 
Retroverted uterine body 



Fig. 5. — Atrophy and Prolapse of Uterus and Adnexa 

(Sellheim.) 



Douglas' pouch 

following the Menopause. 



cease to do so at a correspondingly early period, so that the average duration of 
the function is about the same in all women. But Cazeaux and Raciborski 
think differently, and they are upheld by the opinion of Guy, which he formed 
from the observation of 1500 cases. These authors think that the earlier a 
woman begins to menstruate, the longer she will continue; believing that early 
menstruation indicates extreme vital energy, and that this continues during the 
entire child-bearing epoch. Thirty years of sexual activity are considered the 
normal duration. Climate and other accidental factors do not seem to have so 
much influence on the cessation of menstruation as on its establishment. The 
menopause is generally ushered in by gradual changes in the amount of discharge. 
There are irregularities in its occurrence, and a diminution in amount, or even at 
times an increase, till finally it ceases altogether. The genitalia all undergo an 
atrophic change and nervous phenomena appear (Fig. 5). Flashes of heat are 



\ 




Fig. 6. — Breast of a Nulliparous Married Woman a Few Days Before a Menstrual 
Period, Showing Changes Identical with Those Produced by Pregnancy. 




Fig. 



7. — Vaginal Mucous Membrane of a Nulliparous Woman the First Day of a Men- 
strual Period, Showing Changes Analogous to Those Produced by Pregnancy. 



INSEMINA TION—IMPREGNA TION. 27 

very characteristic, and both the physical and mental being may undergo altera- 
tions. There is a more or less constant tendency to obesity at the time. The 
notions among the laity as to the great dangers of the menopause are, without 
doubt, greatly exaggerated. It is not uncommon to see a woman who for years 
has suffered from uterine and other complaints seem to enjoy robust health after 
this trying period has been passed. Statistics conclusively prove that mortality 
at this time is no greater than at any other period. Some have noted that in 
certain cases, especially of unmarried women, there is a loss of feminine traits 
and the assumption of certain anatomical male characteristics — a more an- 
gular form, a harsher voice, or even the development of an imperfect beard or 
moustache. 

III. INSEMINATION. 

Definition. — By insemination is meant the deposition of the seminal fluid 
within the genital tract of the female during sexual intercourse. 

Phenomena. — Before conception can take place there must be a meeting and 
fusion of the vital elements of the two sexes. This is brought about by coitus or 
copulation, by means of which the semen of the male is deposited in the vagina of 
the female. This act is called insemination, although fecundation does not follow 
unless the ovum and spermatozoon come together and amalgamate. When this 
occurs, the woman conceives and enters upon the period of pregnancy or gesta- 
tion. The orgasm is the climax of the sexual act. Its normal occurrence is 
simultaneous in the male and female, and makes conception more probable. 
When it is not simultaneous, the cervical alkaline mucus protects the spermatozoa 
from the acid secretion of the vagina. The collection of semen covering the 
cervix permits the spermatozoa, by virtue of their inherent power of locomo- 
tion, to enter the uterus. This explains the occurrence of conception in cases 
in which the woman has been apathetic during sexual intercourse, having no 
orgasm, or when she was unconscious from any cause. The time at which insemi- 
nation is least likely to be followed by fertilization is from the seventeenth to the 
twenty-third day after menstruation has ceased. It is most apt to occur on the 
first dav after menstruation. 



IV. IMPREGNATION. 

Synonyms. — Fertilization; Incarnation; Fecundation. 

Definition. — By impregnation is meant the union of the ovum and the sperma- 
tozoon. A woman who has never given birth to a child is called nulliparous, or a 
nullipara, and her condition is termed nulliparity. The state of capacity for 
having children is called parity. When a woman is pregnant for the first time 
she is said to be a primipara, or a primigravida, or a primigravidous woman, or in 
the -condition of primigr avidity. In succeeding pregnancies she is a multipara, 
or a multigravida, a multigravidous woman, or in the state of multiparity. 

The Semen. — The medium by which the spermatozoa reach the female gen- 
erative organs is the semen. The semen is a thick, viscid, albuminous fluid, 
whitish, yellowish, or opalescent in color, with a peculiar odor that has been 
likened to lime or to the filings of bone. It consists of the secretion of the testi- 
cles together with that of the prostate and Cowper's glands. It is composed of 
the liquor seminis, in which are found microscopically the seminal granules and 
numerous minute anatomical elements termed spermatozoa, which are the vital 



28 PHYSIOLOGY OF THE FEMALE GENITAL ORGANS. 

elements. The liquor seminis, which on chemical examination yields 82 per cent, 
of water, holds in solution a mucilaginous, odoriferous body called spermatin, as 
well as protein matter, fats, phosphates, chlorides, and other inorganic materials. 
The Spermatozoa. — Each spermatozoid (Fig. 8) consists of a flat oval head, 
which measures about -goVo i ncn ("STo" mm in width, and represents the nucleus 
of an epithelial cell; a small body, and a very long filiform tail, or flagellum, 
which in the living spermatozoon is in constant motion. The general appearance 
of a spermatozoid is that of a tadpole. These little bodies come from the special- 
ized sperm cells of the epithelium of the seminal tubules in the testicles. The 
profile of the spermatozoid is pyriform in shape, and its entire length is -q^-q to 
4^-q- inch (0.05 to 0.06 mm.). The spermatozoa, the most important elements, 
are not passive constituents of the liquor seminis, simply floating in this medium; 
they are endowed with motility, and seem to dart hither and thither as though 
endowed with volition. It is difficult to realize, in watching the curious move- 
ments of these minute organisms, as they advance now en masse, now singly, at 

times diving down, then coming to the surface again, 
then in their gyrations skilfully avoiding obstacles many 
times their size, that they are not to a certain extent 
possessed of the power of voluntary motion. How- 
ever, these motions are doubtless due to the undula- 
tory vibrations of the tail, which depend purely upon 
molecular tissue changes like those which give rise to 
the movements of ciliated epithelium, or to the ameboid 
movements of protoplasm. The rate of motion of the 
spermatozoa has been variously estimated; Henle states 

that they travel an inch in seven to twelve minutes, or 
Fig. 8. — Human Sper- £ , ■* , . , , , . . 

matozoa. x 360. 1. irom the hymen to the cervix m three hours (bims). 

Viewed from the sur- They have been found within the female genital organs, 

me?' 3 2 :Sikd d sem?nai with this P ower of motion unimpaired, eight to ten 

filament. 4. Sperma- days after they were deposited there. As soon as the 

tozoon .of ox:_ a, head; spermatozoa are deprived of this motility their vitaliz- 

main?piece." P Tne' end- in S P ower is lost - Environment has most to do with 

piece and the demar- the retention of this power. Extreme heat and cold or 

cation of these parts excessively acid or alkaline secretions will destroy them. 

with this magninca- Mercuric chloride has a most untoward effect upon 

tion. — (Stohr.) them, as have also the mineral poisons and lack of water. 

They may be dead when ejaculated, as the result of 

disease or catarrh of the seminal vesicles or alcoholic or sexual excess; or they 

may be absent from the seminal fluid consequent upon anatomical defect, or 

inflammation and obliteration of the seminal ducts. The seminal granule, or 

accessory corpuscle, is that part of the cell which is extruded in the development 

of the spermatozoon, and is analogous to the polar globule in the maturation of 

the ovum. The fifteenth or sixteenth year marks the first appearance of the 

spermatic particles in the sexual discharge ; although there is frequently a seminal 

discharge several years earlier, it seldom contains these elements. Very often 

spermatozoa disappear from the seminal fluid of old men, sixty-five years being 

the average age, though many exceptions to this rule are on record. The amount 

of spermatic fluid ejaculated in sexual congress averages about 1 dram (3.7 c.c.) 

and the number of spermatozoa, as estimated by Lode, is 226 to 900. . If much 

in excess of this, the condition is termed polyspermism; while if much less, the 

condition is pathological, and is designated as oligospermism. 

Ascent of the Spermatozoa. — Many theories have been suggested as to the 




IMPREGNATION. 29 

method by which the spermatozoa reach the uterus, one of the oldest being that 
of Johann Muller, who thought that the semen was forced in by the piston-like 
action of the penis. Litzmann, Wernicke, and Beck proposed the aspiration 
theory, according to which the hood-like layer of the uterus contracts, forcing the 
cervix down into the lake of spermatic fluid, then, relaxation following, the 
semen is aspirated into the canal. Kristeller's idea was that the cervical canal 
was filled with a plug of mucus from the cervical glands ; just as in the last- 
mentioned theory, the uterus contracting, pushes the mucus plug down into the 
semen, then relaxing, brings back the fertilizing fluid. Marion Sims' view has 
been received with the greatest favor. It is that the semen forms a lake in the 
posterior cul-de-sac, and, the cervix dipping in, the fluid passes up into the uterus. 
A proof of the truth of this theory is offered by the observation of the great 
infrequency of pregnancy in cases in which uteri, after operation, cannot dip into 
the spermatic fluid. It was formerly thought that the current produced by the 
cilia of the uterus carried the spermatozoa along their upward path, while the 
tubal cilia wafted the ovum toward the uterus; but Hofmeier, several years ago, 
showed that the ciliary motion was all in the same direction, toward the outlet 
of the uterus. Tubal pregnancy shows that the spermatozoa must get into the 
tube by their own inherent motion. Occasional cases of pregnancy in which 
conception occurs through a minute opening and an almost imperforate hymen, 
and also one recorded case in which no apparent opening existed, prove the 
extreme motility inherent in the spermatozoa. 

Place of Meeting of Spermatozoon and Ovum. — Various authorities have 
located the point of fecundation in the uterus, tubes, and ovary, and isolated 
observations are on record showing that fecundation may take place in any one 
of these organs. For a long time the view held by Wyder and Tait was in 
favor. They thought that the ovum was fertilized in the upper part of the 
uterus; Tait went so far "as to say that tubal pregnancy could not occur in a 
normal tube. Bischoff, in the early part of this century, found spermatozoa in 
motion on the lower surface of the ovary. Hyrtl found in the tube an unim- 
pregnated ovum five days after the end of the menstrual period. Duhrssen 
found spermatozoa in the tube three and a half weeks after the last coitus. 
Spermatozoa have been found alive in the tube of a bat six months after copula- 
tion, and in the queen bee for years. Reasoning from these observations, the 
conclusions may be drawn that spermatozoa reach the uterus by reason of 
their own motility, aided by other mechanism; that they then pass to the tube 
and wait for the ovum, which may or may not be fertilized. 

Relation between Impregnation and Menstruation. — It has been practically 
proved from observations on the wives of sailors and from artificial impregnation* 
that the most favorable time for impregnation is immediately after menstrua- 
tion; and also that the spermatozoa may retain their vitality in the vagina for at 
least seventeen days, even through a menstrual period. Instances are known in 
which insemination, occurring just before a menstrual period, was followed by 
pregnancy and delivery at term, t Menstruation under such circumstances may be 
perfectly normal, and the downward current of blood does not interfere with the 
upward passage of the spermatozoa to the Fallopian tubes. His J examined 
sixteen embryos with the utmost care. He found that in twelve the stage of 
development proved that impregnation had occurred, not at the time of the last, 
but at what would have been the next, menstrual (first missed) epoch, had not 

* Bossi: " Nouvelles Archives d'Obstetrique et de Gynecol ogie," Paris, April, 1S91. 
t Milne Murray: "Edinburgh Med. Jour.," Sept., 1892. 
J'Anatomie menschl. Embryonen," Abth. I. V., II., Leipzig, 1882. 



30 PHYSIOLOGY OF THE FEMALE GENITAL ORGANS. 

the woman become pregnant. The remaining four embryos in their develop- 
ment corresponded to impregnation occurring at the last menstrual period. 
Duncan says, in this connection, that when a fertilizing insemination takes place 
just before the period is due, the latter frequently "does not take place at all, or 
only very scantily; the uterine system, as it were, anticipating the conception 
and preventing the failure which might result from a free discharge of blood." 
It is quite evident that such cases, occurring in married women, would be very 
liable to be considered "cases of gestation protracted a month." 

Unconscious Impregnation. — A woman may become pregnant in a state of 
partial or complete unconsciousness. In cases of rape young girls have been 
impregnated while unconscious as the result of fright, a blow, drugs, or alcohol. 
Impregnation during unconsciousness as the result of anesthetics, chloroform, 
ether, or nitrous oxide is also possible. Artificial impregnation, the seminal fluid 
having, with suitable instruments, been injected directly into the uterus, has 
also been successfully performed. Brouardel,* who has studied and written 
upon this subject, states that copulation and impregnation can occur in a woman 
without her knowledge during hypnotic sleep. "That a woman should be un- 
conscious both of the fact of sexual intercourse, and also continue unconscious of 
the resulting pregnancy up to the birth of the child, we decline to believe, unless 
she was feeble-minded or idiotic." (Reese.) 



V. RAPE.f 

Definition. — Rape, derived from raptus mulierum, signifies carnal knowledge 
of a female by a man, forcibly and unlawfully, without her consent. It may, 
however, be committed by fraud or by intimidation. 

Law of Rape. — Female chastity has been carefully guarded by law since the 
early ages, and legal penalties for the crime are subject to great variation in the 
different countries. Common law declares a female under thirteen years of age 
incapable of giving consent. Carnal knowledge betwean thirteen and sixteen is 
regarded as*a misdemeanor ; it is not a crime if the age is over sixteen and there is 
consent. The testimony of the prosecutrix alone is considered legally com- 
petent, since she and the offender are generally without other witnesses. As 
false accusations of rape are common, the corroborative testimony of medical 
evidence is generally required. In 600 accusations I could find evidences 
of penetration in but 386 instances. In 212 there was no evidence what- 
ever of penetration of the genital organs and in two cases menstruation and 
chancroids rendered the diagnosis uncertain. The examination should be made 
as soon as possible after the assault, and the physician should carefully -note the 
time of his examination and try to obtain by inquiry the exact time of assault. 
The female should be allowed no time to prepare for the examination. Several 
points should be kept in mind and noted by the physician: (1) Signs of violence 
on the genitals of the female; (2) signs of violence on her body or that of the 
defendant; (3) evidence of blood or semen on the body or clothes of either; (4) 
the existence of venereal disease, syphilis, chancroid, or gonorrhea, .in one or both 
of the individuals concerned. The evidence of masturbation and criminal 
assault may be present in the same instance, and in the majority of cases the 

* " Gaz. des Hopitaux," 1877. 

t See more exhaustive article, "Medico-legal Consideration of Rape," by Bdgar and 
Johnston, "Medical Jurisprudence, Forensic Medicine and Toxicology," Witthaus and 
Becker, vol. 11. 



RAPE. 31 

medical expert can swear only to the "penetration of some blunt instrument." 
In the eyes of the law any attempt even to touch the female genitals or breast 
without consent is criminal or indecent assault. The subject may be treated in 
four parts : ( i ) Rape on females after puberty ; ( 2 ) rape on children and infants ; 
(3) rape by boys and women; (4) rape on the dead (necrophilia). False accu- 
sations are considered throughout the text. 

1. Rape on Females after Puberty. — The signs of virginity are as follows: 
The labia majora lie close together, covering the meatus urinarius; they are firm 
and well filled out. The labia minora are a bright pink color, and are completely 
covered by the larger folds. The fourchette and posterior commissure are often 
destroyed by the first delivery, but they are seldom injured by sexual intercourse. 
In 386 penetrations the fourchette was lacerated in but 17 of the cases observed 
by the author. The hymen is the most convincing sign of virginity. It is a 
membranous structure guarding the entrance to the vagina and making a line of 
demarcation between it and the external genitals. There are four chief forms, 
with many variations. These are: (1) A form with a central, antero-posterior 
opening; (2) the semilunar; (3) the annular; and (4) the diaphragmatic. 
(Figs. 9 to 33.) * The first and third are the most common varieties. The imper- 
forate hymen is a pathological condition. Is the presence of an intact hymen 
evidence of virginity? Although the presence of the hymen is not absolutely 
invariable, still it is unquestionably the most valuable physical sign. However, 
even when it remains uninjured, it does not offer positive proof that rape has not 
been committed. This is especially true in the case of young children, in whom 
it is deeply placed, and the organs are undeveloped; for it must be remembered 
that the slightest penetration is a crime. Authentic cases in which prostitutes 
have had perfectly preserved hymens are on record. f It may even persist after 
delivery, remaining as a loose ring. % Does the absence of the integrity of the 
hymen, on the contrary, indicate defloration? The greatest care must be exer- 
cised in deciding this question. The hymen may be injured manually, as in one 
of my cases by a midwife; or it may be destroyed by accident, as by falling 
astride of an object; again, violent exercise may rupture it — e. g.., horseback- 
riding. Congenital absence of the hymen is known (Fig. 35). Surgical opera- 
tions or vaginal examinations, roughly conducted, not infrequently cause rup- 
ture. The breasts are only slightly affected by handling and sexual indulgence. 
One sign alone cannot afford positive proof of virginity, but all taken together 
give assurance of it. It is well known that the use of vaginal astringents may 
tone up and narrow the vagina and even restore the hymen to a great degree. In 
complete recent defloration the hymen will furnish the most convincing proof, 
but the external genitals may also be inflamed to a greater or less extent ; and if 
the inflammation is extreme the patient's movements will be interfered with and 
she will evince a great dread of opening the thighs. These signs are most im- 
portant and are seldom simulated. There may also be signs of violence on the 
genitals, thighs, abdomen, or perineum. The hymeneal tear itself may be 
attended with pain and difficulty in walking. Attention should be paid to the 
manner in which the hymen is torn, as well as to the appearance of the edges of 
the segments. As a rule, healing takes place in from eight to twelve, or at most 
twenty, days. Rarely the tears of the hymen unite; if they do, a cicatrix may 
remain. Incomplete recent defloration is usually seen in young children. Non- 

* Figs. 9 to 7,7, inclusive, and Fig. 35, are from E. Von Hofmann's "Atlas of Legal 
Medicine." 

t Grey's " Forensic Medicine," p. 49. 

% Stolz: "Annales d'Hygiene," 1873, t. 2, p. 148. 



32 



PHYSIOLOGY OF THE FEMALE GENITAL ORGANS. 






Fig. 9. — Circular Hymen 
with Wide Opening and 
Circular Smooth-edged 
Margin of Equable 
Height Throughout. 



Fig. 10. — Semilunar 
Hymen. 



Fig. ei. — Semilunar 
Hymen. 




/*f< 





Fig. 12. — Hymen of New- 
ly Born Child with 
Deep Notches. to the 
Right and Left. 



Fig. 13. — Circular Hymen 
with Deep Congenital 
Notches. Edges Smooth 
and Rounded. 



Fig. 14. — Deep Irregular 
Notch of the Hymen of 
a Newly Born Infant. 






Fig. 15. — Congenital 
Deep Irregular Notch 
of Hymen. 



Fig. 16. — Fimbriated Hy- Fig. 17. — Serrated or Fim- 
men in a Virgin. briated Hymen in a Vir- 

gin. 



I 



RAPE. 



33 






Fig. 18. — Hymen Bipar- 
tus or Septus or Di- 
vided Hymen. 



Fig. 19. — Hymen Bipartus 
or Septus or Divided 
Hymen. 



Fig. 20. — Hymen Septus in 
an Unmarried Woman 
Twenty-four Years 
Old. Strong and Thick 

Septum. 





^ 




Fig. 21. — Large and Small 
Openings in a Divided 
Circular Hymen. 



Fig. 22. — Circular Hymen 
of an Adult Parous 
Woman. 



Fig. 23. — Circular Hymen 
of Virgin, Age Twenty 
Years. Hymen Partim 
Septus. 






Fig. 24. — Circular Hymen 
with Congenital Trans- 
verse Septum in Girl of 
Seventeen. 



Fig. 25. — Divided Hymen 
of Infant with Thick 
Transverse Septum. 



Fig. 26. — Circular Hymen 
of Child, Age Twelve, 
Ruptured by Rape. 
Death in Ten Days from 
Peritonitis. 



34 



PHYSIOLOGY OF THE FEMALE GENITAL ORGANS. 






Fig. 27. — Circular Hymen 
with Old Healed Lac- 
eration to Left and 
Right. 



Fig. 28. — Remains of Hy- 
men Six Months after 
Delivery at Term. Car- 
uncul.e myrtiformes. 



Fig. 29. — Hymen after 
Several Labors. Shape 
Originally Circular. 






. .jT 






Fig. 30. — Divided Hymen 
of a Prostitute Eigh- 
teen Years Old. Coitus 
Took Place through the 
Left Opening. 



Fig. 31. — Remains of>' a 
Divided Hymen after 
Defloration and Par- 
turition. 



Fig. 32. — Hymen from a 
Woman, Age Twenty- 
nine, Who Died in Sixth 
Month of First Preg- 
nancy. Originally a Di- 
vided Circular Hymen. 





Fig. ^^. — Hymen from 
. Elderly Multiparous 
Woman. 



Fig. 34. — Parental Rape 
on Infant Eight Months 
Old. Complete Lacera- 
tion of Pelvic Floor. — 

{New York Children's So- 
ciety.) 




Fig. 35. — Congenital Ab- 
sence of Hymen. Mas- 
culine Pseudohermaph- 
rodism. Female Infant 
with Normal Internal 
and Hermaphroditic Ex- 
ternal Organs. 



RAPE. 35 

recent defloration may be told chiefly from the absence of complete hymen, its 
remnants only remaining. The vulval canal is likely to be dilated. 

Conditions Simulating Defloration. — Traumatism, all ulcerative and gan- 
grenous affections of the pudendum, chancre, chancroid, mucous patches, and 
herpes progenitalis may each cause such destruction that the results may simu- 
late those caused by intromission. An extreme degree of leucorrhea or excessive 
menstrual discharge may cause dilatation of the vagina and superficial ulceration 
of the mucous membrane, like those produced by coitus. Again, marks of vio- 
lence must be considered. Stains of blood and semen should be carefully exam- 
ined. Vaginal discharges must be scientifically considered. Leucorrhea must 
be differentiated from gonorrhea. The absence of any one of the characteristics 
of the gonococcus will make the diagnosis of gonorrhea doubtful. Further, the 
specific lesions of syphilis and chancroid should be carefully distinguished. Both 
accuser and accused must be examined; the latter being of the greater impor- 
tance. Of the accidents following rape, besides the direct accidents already con- 
sidered, the effect on the health and mind of the victim may be most alarming. 
Convulsions have occurred; despair may lead to melancholia and finally to 
suicidal mania. Early death not infrequently occurs. Hysteria, chorea and 
epilepsy have all been noted. Death may supervene without violence, following 
syncope. The congestion of the various organs, including the brain and cord, 
may result in fatal hemorrhage into their substance or into other cavities. 
Murder may follow rape without the intention of the criminal. The ravisher 
may practice anthropophagy. Rarely the victim is not violated, her murder 
alone sufficing to satisfy the passion of the assailant. The violence becomes 
equivalent to coitus. 

Can a woman be violated against her will? The best authorities believe fully 
that a mature woman, in full possession of her faculties, cannot be raped by a 
single man against her will. In the case of a child or an old woman, or when 
there are two or more assailants, the conditions are very different. Terror may 
in certain instances cause paralysis. Can rape be accomplished during natural 
sleep? This is probably unlikely, indeed impossible, in the case of a virgin. 
Rape by fraud, unfortunately, is widely prevalent, as in the impersonation of a 
husband. Rape on psychopathic individuals, in the hypnotic state, and during 
unconsciousness from narcotism, alcoholism, and anesthesia has occurred. 

2. Rape upon Children and Infants. — This is far more common than the 
crime on adults, for it is easier to perpetrate, and there is a wide-spread super- 
stition among some nationalities that intercourse with a virgin is a sure cure 
for venereal disease. On account of the disproportion between the organs, the 
crime usually consists in placing the head of the penis between the labia majora 
or the thighs of the child. There are great differences between the genital organs 
of the child and the adult. The whole vulval canal is relatively much longer in 
youth than after puberty. It is important to examine the fourchette and com- 
missure for evidence of rape in children, since, on account of the very small open- 
ing, injury is more common in their case than in that of mature women. The 
hymen is situated very deep in the child and there is almost no possibility of 
intromission. The pubic arch, as well as the vagina and its entrance, are very 
narrow. One of our 600 cases was rape by the father upon his daughter eight 
months old, causing complete laceration of the perineum from vagina to rectum. 
The hemorrhage was controlled and the perineum repaired with sutures (Case 
No. 70,542) (Fig. 34). 

G. P.; born in United States; aged eight months; seen February 17, 1893, soon after 
assault. The external genital organs were found to be greatly swollen, contused, and cedema- 



: PHYSIOLOGY 7 THE FEMALE GEXITAL ORC- 

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15 



4. Rape on the Dead, or Necrophilia. 



\--- 



: r : : : 

■.-~:.7': 



* Rust's "New Yoric 
303, cfc rn sp 4. 



HYGIENE OF THE SEXUAL FUNCTIONS. 37 



VI. HYGIENE OF THE SEXUAL FUNCTIONS. 

The health of the young girl should be most carefully guarded with a view of 
preserving the integrity and vitality of the sexual functions. The difference in 
vigor between the American women and their English and Continental sisters 
points strongly to the superiority of the habits of life of the latter. The vulnera- 
bility of the female pelvic organs is well known, and most of the dangers attend- 
ing their treatment in former times have been done away with by modern aseptic 
technique. The causes of gynecological disease are (i) predisposing and (2) 
exciting. Chronologically considered, the first predisposing cause is heredity. 

Heredity. — The untoward results of this factor are seen either in the direct 
transmission from mother to daughter of specific physical defects, or in general 
ill health as the heritage of ill-conditioned parents. It is generally accepted that 
the children of parents of advanced years are apt to be less vigorous than those of 
younger progenitors. 

Education. — This has a powerful influence on the genital functions. Great 
concentration in study uses up the nerve energy of the body and leaves the uterus 
and ovaries without their legitimate share. Especially does close application to 
music have a deleterious effect on these functions, by its emotional influences and 
the expenditure of nervous energy which it demands. Hyperemia of the pelvis, 
however caused, tends to produce disease of its contained organs. Sexual excite- 
ment produced either through mental or physical influences — e. g., the observa- 
tion of obscene sights or pictures, or masturbation — is also a cause. 

Mode of Life. — Lack of exercise and of outdoor air is a fruitful cause of disease 
and poor pelvic circulation. In the last few years attention has been called to 
these defects in the life of the average American girl, and athletic sports, com- 
paring favorably with those of men, have been instituted. Neglect of the skin 
as the medium for so much of the vitiated excretions of the body is particularly 
noted among the poorer class of foreigners. The amount and kind of food exer- 
cises an important influence on the young girl's health. A common habit, which 
grows stronger with every repetition, is the omission of breakfast. Soda-water, 
ice-cream, and candy are most harmful if taken to excess, as they very often are. 
Indigestible and non-nutritious foods should be avoided. All these factors tend 
to produce anemia and general ill health. Neglect of the excretions is a very 
common fault in young girls, as well as in women, and especially those with 
gynecological troubles. The bowels, instead of moving once or twice a day, as 
they should normally, are evacuated perhaps once a week. The poisons of the 
waste matter are absorbed and sapremia results. The circulating impurities 
show themselves in the anemic appearance, lack of energy, headache, and 
neuralgic pains. Then, again, the bladder is often not emptied when it should 
be; consequently distention and displacement of the uterus by the enlarged 
bladder, or paralysis of that organ, or cystitis may result. Disregard of the 
menstrual periods causes much trouble. Girls during these periods are very apt 
to make no difference in their manner of life from that at any other time. 
Oftentimes violent exercise and exposure at these periods bring on serious con- 
sequences. 

Dress. — The manner of dressing has much to do with health or disease ; it is 
especially faulty amongst women. Tight garments for any part are most inju- 
rious. The disproportionate arrangement of clothes as to the warmth they 
afford is injurious; foi instance, when the lower abdomen is not sufficiently pro- 



38 



PHYSIOLOGY OF THE FEMALE GENITAL ORGANS. 



tected. Incorrect corsets exert a most baneful effect on the female organism. 
The old-fashioned garment, even when worn loose, exerts a pressure of thirty 
pounds (Fig. 36). The abdomen suffers from this more than the thorax. There 
is a thinning and weakening of the abdominal wall, which becomes relaxed and 
pushed forward, in the upright position, by the liver and intestines. In the sitting 
posture, the pressure exerted by the abdominal wall, which should be backward 
against the spine, is exerted downward toward the pelvis, and causes bulging of 
the vulva even to the extent of half an inch (1.27 cm.). Corsets made to sup- 
port the lower abdomen have not these objections (Fig. 37). High heels should 





Fig. 36. — Corset Improperly Fitted, so 
that Abdominal Contents are Pushed 
Downward and Backward, thus Fa- 
voring Posterior Uterine Displace- 
ments. Note the unnatural pressure 
upon the breasts. — (Photographed from 
life.) 



Fig. 37. — Properly Fitting Corset. Hy- 
pogastrium Supported from Below 
Upward. Breasts Free and only 
their Lower Portions Supported. — ■ 

(Photographed from life.) 



be avoided, for when they are worn, especially by the young, whose bones and 
articulations are soft and pliable, they not only distort the foot but often en- 
gender other troubles, such as neuralgic pains in the legs, alterations in the shape 
of the pelvis, and curvature of the spine. Ordinary social pleasures entailing 
late hours have a very bad effect on a girl's nervous organization. 

Sexual Life. — Normal sexual intercourse, even when frequent, is not apt to 
injure a healthy woman. But irregularities indulged in will bring in their train 
many complaints. Marriage, if pelvic disease exists, is often attended with dire 
results, and causes much misery to both husband and wife; but even celibacy 
is not immune from troubles. The growth of fibromata seems especially active 



HYGIENE OF THE SEXUAL ORGANS. 39 

in the uteri of unmarried women and in those who have never borne children. It 
would seem that the energies of that organ, which are normally applied to the 
formation of a child, being deprived of that object, are free to take part in the 
production of a new growth. 

The Prevention of Reproduction. — The act of reproduction may be set at 
naught in a twofold manner: (i) By conditions which prevent the union of the 
reproductive units, and (2) by death of the embryo which results from the union 
of these units. 

1. Non-impregnation. — If the conditions which oppose the union of the 
reproductive units are spontaneous and natural, or the result of accident or dis- 
ease, the subject has no necessary connection with obstetrics, and is considered 
in full in writings upon impotence and sterility. When, however, non-impregna- 
tion comes about solely through conscious efforts of the participants, we have a 
condition of affairs known as artificial or facultative sterility, a subject which has 
a distinct obstetrical significance, because in order to save the lives of certain 
women, and at the same time to avoid feticide, it is justifiable to prohibit impreg- 
nation. Unless either the life or the health of the woman is certain to be wrecked 
by bearing a child, or unless she is incapable of giving birth to a normal living 
child, the prevention of impregnation is justly regarded as a violation of the 
moral law, an injury to the State, and to a certain extent a detriment to the health 
of the participants. Technically, at least, it is a violation of the criminal code, 
the various contrivances used for the prevention of conception being regarded as 
contraband. A sharp distinction should therefore be made between artificial 
sterility which is practised to save the more valuable life, and that which simply 
seeks to prevent reproduction in itself. 

Therapeutic Prevention. — This expression signifies the prevention of impreg- 
nation in cases in which the reproduction of a healthy, living child is quite impos- 
sible, or if possible would mean either the death or permanent invalidism of the 
mother. 

Indications. — These comprise: (1) General conditions in the mother which 
are likely to be transmitted to the child — syphilis, the tuberculous dyscrasia, 
insanity, epilepsy. (2) General conditions in the mother which would be aggra- 
vated to such an extent by reproduction that her death would be determined, or, 
if inevitable in any case, greatly accelerated — heart disease, tuberculosis, cancer, 
nephritis, diabetes, etc. (3) Conditions in the mother which, by producing 
extreme dystocia, would make Caesarean section the only route by which the 
child could be born — high degrees of contracted pelvis, obstruction of the birth 
tract by inoperable tumors. 

Management. — In the case of a woman who furnishes any of the indications 
just enumerated, it is the duty of the physician to inform the patient and her 
husband of all the consequences of impregnation under the circumstances. If 
the matter is left to him to decide, he must insist that conception shall not occur. 
Much further than this he can hardly go. Realizing that cohabitation without 
intercourse is a condition difficult to realize, he may suggest a separation, tem- 
porary or not. If this is refused, coitus might be permitted during the so-called 
agenetic period of the intermenstrual cycle (from the seventeenth to the twenty- 
fourth day after cessation of a period). The married pair should be informed 
that this precaution simply diminishes the risk, and that if the latter is assumed, 
impregnation, if it occur, will necessitate interruption of the pregnancy, which 
will submit the mother to more or less danger, hardship, expense, etc. If the 
matter is left to the physician, he can hardly sanction coitus under any circum- 
stances. Sooner or later the question will arise as to the use of so-called illegiti- 



40 PHYSIOLOGY OF THE FEMALE GENITAL ORGANS. 

mate measures of preventing conception. If asked the objections to these, he 
must take the stand that every one of these preventive measures constitutes an 
abuse of a normal function. The coitus interruptus, coitus reservatus, simple or 
antiseptic douching after coitus, wearing of coverings for the penis or obturators 
for the uterus, etc., are all unphysiological and many of them untrustworthy. A 
physician can never sanction anything which is frankly unphysiological, and 
should explain to his patients that the act of intercourse consists in three distinct 
stages: (i) The male organ becomes completely rigid, passing from a state of 
flaccidity into erection. (2) The second stage comprises intromission, friction, 
and the orgasm or crisis. (3) The act of copulation is not concluded by the 
orgasm. The penis, therefore, should not be withdrawn at once, but allowed to 
remain until the gradual subsidence of the erection leaves it in its original flaccid 
state. This final stage of copulation undoubtedly plays an important role in 
impregnation, and if it is shortened or omitted, the consequences appear to be 
unpleasantly felt by both sexes. In other words, withdrawal of the penis im- 
mediately after the orgasm is virtually a coitus interruptus. During this stage 
the semen should remain in the upper part of the vagina, just opposite to the os 
and in contact with it. Its presence is believed to excite the latter to dilate 
rhythmically and aspirate some of the male fluid. If the penis is withdrawn at 
once after the orgasm, the semen often follows it out of the vagina, and this 
escape is further facilitated if the woman rise quickly to bathe. It is character- 
istic of the various illegitimate measures for preventing conception that all of 
them interfere with the second or third stage of coitus. As a general rule, the 
less unnatural the act, the more untrustworthy the method. The consequences 
to the woman of these illegitimate practices are in part: (1) An unnatural local 
congestion which leads to oophoritis, endometritis, leucorrhea, dysmenorrhea, 
sterility, metrorrhagia, and cancer of the uterus; (2) neuroses of various kinds, 
spinal irritation, neurasthenia, etc. In the man the consequences are similar in 
character, with the addition of dissatisfaction with imperfect coitus with his 
wife, which often foments dislike, unfaithfulness, marital infelicity, and divorce. 
If impregnation is actually contraindicated in a given case, the practitioner can- 
not recommend any of the illegitimate modes of prevention of conception 
because they are either harmful, or untrustworthy, or both. There is, however, 
one course possible, which may be recommended as both safe and efficacious, 
and one which can hardly be abused. That is, obliteration of the Fallopian 
tubes for a short extent by the vaginal route. 

This course is unobjectionable in theory from any standpoint; yet I fear it 
hardly constitutes a solution to the problem. 

2. Interruption of Pregnancy. — After pregnancy has begun it may be in- 
terrupted by the natural death of the fetus from disease, trauma, etc. This is con- 
sidered under the heads of death of the fetus, abortion, etc. (Part III). Preg- 
nancy intentionally ended is feticide. Criminal feticide is the destruction of fetal 
life for no other reason than to avoid child-birth. This is considered under the 
head of criminal abortion (Part III). Therapeutic feticide, on the contrary, con- 
sists in taking the fetal life when non-interference with pregnancy would result 
in the death or permanent invalidism of the mother, or the birth of an abnormal 
unit of society. The subject of therapeutic feticide is considered under " Ob- 
stetric Operations " (Part X). 

Child-birth. — Child-birth not infrequently is the origin of disease of the pelvic 
organs, which hinders or prevents their normal functions. These troubles may or 
may not result from improper medicinal or surgical treatment. Abortion is a 
fruitful cause of pelvic trouble. Puerperae should receive the most careful 



HYGIENE OF THE SEXUAL FUNCTIONS. 41 

attention, and should be kept in bed till the uterus has contracted back into the 
pelvis. In order to avoid the perils of gonorrheal and syphilitic infection, these 
subjects are now receiving like attention with tuberculosis. The application of 
the general principles of aseptic midwifery and early operative measures in case 
of delayed labor, with immediate surgical attention given to lesions of the soft 
parts, are doing much to prevent the frequent pelvic troubles so common in 
former years. 

Climacteric. — The climacteric, although a physiological process, is a period 
during which various diseases may show themselves. Nervous phenomena are 
among the most common disturbances. The most serious occurrence is the 
appearance of carcinoma, either in the uterus or in the breast. During this 
period the bowels should be kept open. Cold bathing followed by brisk rubbing, 
and lukewarm baths taken at intervals of a few days, tend to calm the nerves. 
The diet should be carefully supervised. The patient should be supported men- 
tally and encouraged by a favorable prognosis. In case of hemorrhage, it 
should be checked just as in ordinary cases. 

Cancer. — There is little possible prophylaxis at present for malignant disease 
of the pelvic organs, but there is hope for the future. As soon as the true cause 
of cancer is discovered, some method of preventing or at least arresting its 
progress will present itself. 

Family Physician. — The family physician should be the guide of the child 
from infancy through the various stages of life up to womanhood. He should 
instruct not only the girl, but her mother also, in regard to the importance of the 
sexual organs, their functions, and their proper care. The generative organs are 
the last to develop, and when the girl is deficient in vitality these organs are the 
first to suffer, for when undeveloped they are most prone to disease. 



PART TWO. 
Physiological Pregnancy* 



I. PHENOMENA PRODUCED BY PREGNANCY WITHIN THE UTERUS.— 
The Ovum ; Maturation ; Fertilization ; Primitive Chorion ; Deciduae ; Seg= 
mentation ; Germ=layers ; Primitive Organs ; Origin of Membranes ; Amnion ; 
Allantois; Chorion; Placenta; Umbilical Cord; Nutrition and Metabolism 
of the Ovum, Embryo, and Fetus; Characteristics during the Several 
Lunar Months ; Evolution and Determination of Sex. 

II. PHENOMENA PRODUCED BY PREGNANCY IN THE MATERNAL OR= 

GANISM. — Local Phenomena in the Genital Tract, Adnexa, Pelvis, and 
Breasts ; General Phenomena in the Digestive System, Heart, Lungs, Liver, 
Nervous System, Blood, Urine, Skin, etc. 

III. THE DIAGNOSIS OF PREGNANCY. 

IV. THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 
V. FEIGNED PREGNANCY— PSEUDOCYESIS. 

VI. UNCONSCIOUS PREGNANCY. 

VII. MULTIPLE PREGNANCY. 

VIII. THE DURATION OF PREGNANCY. 

IX. CALCULATING THE DATE OF CONFINEMENT. 

X. THE EXAMINATION OF PREGNANCY.— Obstetric Asepsis of Patient and 
Physician; Objects, External or Abdominal; External Pelvimetry; In= 
ternal or Vaginal; Internal Pelvimetry; Rontgen Pelvimetry; Pelvigraphy; 
Indirect Pelvimetry; Cliseometry; Cephalometry. 

XI. THE HYGIENE AND MANAGEMENT OF PREGNANCY.— Prophylaxis ; 
Exercise ; Diet ; Drink ; Bowels ; Fresh Air ; Care of Skin, Clothing, Breasts ; 
Mental Condition; Examination of Urine; Sexual Intercourse. 



THE PHENOMENA PRODUCED BY PREGNANCY IN 
UTERUS. THE DEVELOPMENT OF THE OVUM, 
EMBRYO, FETUS, FETAL MEMBRANES, 
AND FETAL STRUCTURES. 



THE 



Introduction. — Pregnancy begins with conception and normally ends with 
labor at the fortieth week. If no complications arise during this time, we have 
a physiological pregnancy (Part II). On the other hand, various accidents may 
bring about a pathological pregnancy (Part III). 

A nulliparous woman, or a nullipara, is one who has never borne a child, 
and the condition is one of nulliparity ; 

A primigravidous woman, or a primigravida (or primipara), is one who is 
pregnant for the first time, and in subsequent pregnancies she is known as a 
multigravidous woman or a multigravida (or multipara). Different degrees 
of gravidity or parity are usually designated by the Roman numerals, thus: 
Ipara, a woman in her first pregnancy; Ilpara, one in her second pregnancy; 
Tllpara, IVpara, Vpara, etc. 

In the following review of the subject of embryology, emphasis is placed iipon the 
growth of the embryo, fetal membranes, and fetal circulation — facts which bear most 
directly upon the subject of obstetrics. For a full consideration of the subject special works 
on embryology should be consulted. Among these, Minot's discussions of difficult points are 
valuable, while the most recent book with an almost exclusive bearing upon human embry- 
ology is Kollmann's "Entwickelungsgeschichte der Menschen." The embryological part of 
Quain's "Anatomy" and Hertwig- Mark's "Embryology" also give excellent accounts of 
the subject. For the latest information one must refer to the monographs which are appear- 
ing in scientific periodicals. His's monumental work * is 
the source of the greater portion of the accurate informa- 
tion on the subject of human embryology. The phenomena 
of the development of the human being in its earliest stages 
have not been adequately worked out; hence the gaps in 
knowledge are usually rilled in by statements from com- 
parative embryology. We shall endeavor to differentiate 
what is known of human development from that which is 
inferential. 



The Ovum. — At birth the ovary of a child is 
believed to contain the maximum number of ova, 




estimated as high as 70,000. These primordial ova 
are typical, spherical cells containing a nucleus 
with a membrane and usually a nucleolus (Fig. 38). 
They are arranged in so-called egg-chains, or egg- 
nests, which extend for some distance into the body 
of the ovary. As the ova develop they increase in 
size until at maturity they are about YT5 inch 
(0.2 mm.) in diameter, surrounded by a porous 

membrane, the zona pellucida or radiata. There is some doubt as to whether 
a cell membrane proper exists within the zona radiata. The cell body, or 

* "Anatomie menschlicher Embryonen," 1880-1885. 
43 



Fig. 38. — Primitive Folli- 
cles from the Ovary 
of a Woman Thirty-two 
Years Old. th, Connec- 
tive-tissue layer; /, epithe- 
lial follicle; z, beginning 
zona pellucida; nu, nucleus 
or germinative vesicle. — ■ 
(After W. Nagel.) 



44 



PHYSIOLOGICAL PREGNANCY. 



vitellus, is protoplasmic and contains a few granules of the food-yolk similar 
to that which forms so marked a feature of the hen's egg. On account of 
this small amount of food-yolk, or deutoplasm, the mammalian egg is said to 
be alecithal (without yolk). The nucleus becomes somewhat eccentrically 
placed and contains a conspicuous nucleolus (Figs, i and 39). The whole 
ovum is encapsuled by the Graafian follicle. The follicles are scattered at 
different levels throughout the stroma of the ovary (compare Ovulation, 
page 17). 

Maturation of the Ovum and Zobsperm. — In many of the lower animals 
a process called maturation of the ovum has been observed, whereby the nucleus 
migrates toward the surface and by an active process of division throws off 
a part of its substance in the form of polar globules, the part remaining in the 
cell being called the female pronucleus or egg nucleus. Polar bodies in different 
stages of development have been found in mammals (Figs. 40 and 41), and 



z.p. 
g.v. 
y. or v. 



Fig. 39. — Ripe Human Ovum. A 
- spherical cell with nucleus and nu- 
cleolus, yolk granules, z. p., Zona pel- 
lucida; y. or f ., yolk or vitellus; g. v., 
germinal vesicle. — (Ajter Nagel.) 




Fig. 40. — Formation.of Polar Glob- 
ules, Mouse. Showing the nu- 
cleus of the ovum dividing to 
form the first polar globule, p. g., 
and at the right a zoosperm, s, 
which has entered at the projecting 
portion. — (Ajter Sobotta.) 



Nagel is said to have seen them in a human ovum. As the result of a some- 
what analogous process of maturation and division, the zoosperm or mature 
male element (Fig. 8) contains a nucleus, — the male pronucleus, or sperm 
nucleus, — which represents only a part of the original nucleus from which it 
was derived. 

Fertilization or Impregnation. — When the two sexual elements come in 
contact in the upper part of the Fallopian tube, the zoosperm enters the ovum, 
where its body becomes indistinguishable (Fig. 41), and a union of the two 
pronuclei takes place. This is considered the essential step in fertilization, 
the union giving rise to a new nucleus called the segmentation nucleus. The 
living process has been followed step by step in lower forms and cumulative 
evidence exists that the same phenomenon occurs in mammals (Fig. 40). Facts 
of this sort exert a powerful influence upon theories of heredity, because it is 
evident that the actual substance derived from both parents goes to form the 




Fig. 41. — Fertilization in the Mouse. Show- 
ing an ovum with two polar globules and the 
male and female pronuclei about to unite, 
g. s. — (After Sobotta.) 





Fig. 42. — Transverse Section of 
the Uterus from a Six-months' 
Fetus at the Level of the In- 
ternal Os. i, Cylindrical ciliated 
epithelium; 2 , connective-tissue stro- 
ma of mucous membrane containing 
blood-vessels; 3, muscular layer with 
arteries; 4, subserous connective tis- 
sue; 5, peritoneal endothelium; 6, 
inlraligamentary connective tissue, 
containing main branches of uterine 
artery. — (Schaeffer. ) 



Fig. 44. — Uterus and Ovum at Seventh or 
Eighth Day. Section through Fig. 43. 
a, Decidua vera; b, d, decidua reflexa; c, 
ovum; o.i., internal os. — (Leopold.) 




Fig. 43. — Uterus and Ovum at Seventh or Eighth Day, showing Decidua Vera. 

o.i, Internal os; a, uterine wall. — (Leopold.) 

45 



46 PHYSIOLOGICAL PREGNANCY. 

new individual and apparently is distributed by subsequent nuclear division 
to every portion of the body (see Impregnation, page 27). 

Primitive Chorion. — During its passage through the Fallopian tube the ovum 
derives more or less nourishment from the parts by which it is surrounded. 
This is accomplished at a very early period by the formation upon all of the 
extra-embryonic somatopleura of a growth of delicate villi which give to the 
ovum even at this time a shaggy appearance. This is the primitive chorion, 
and the whole ovum at this time is sometimes called the chorionic vesicle. 

The Deciduae. — The uterus prepares for the reception of the fertilized ovum 
by the premenstrual swelling of its mucosa which forms a pulpy nidus for its 
new occupant. If the fertilized ovum does not then appear, menstruation 
takes place. If the fertilized ovum remains in the genital tract, then the uterine 







c/- 




•:-•- ■— ;> V 












\ v ; " ft 

Fig. 45. — Microscopic Section through an Ovum in Situ at the Seventh or Eighth 
Day, showing Uterine Wall, Decidua Vera and Reflexa. — (Leopold.) 

mucosa undergoes changes by which it is converted into decidua. That formed 
in pregnancy is called decidua graviditatis . The normal uterine mucosa is thin, 
averaging from 0.039 to 0.117 inch (1 to 3 mm.) in thickness. Its most marked 
change in pregnancy is the increase in this dimension, for in this condition it 
often attains ^ inch (1 cm.) in thickness. It is very vascular, soft and velvety 
in consistence, and its surface is wavy or undulating, studded with depressions 
which correspond to the openings of glands. With the beginning of pregnancy 
the decidua comprises three parts: (1) Decidua vera is the hypertrophied mucous 
membrane of the entire uterus (Figs. 42, 43, and 46). It atrophies in the 
last third of pregnancy and is cast off in part with the membranes at labor and 
in part with the lochia. (2) Decidua serotina, placental serotina or decidua 
basalis, is that part of the decidua vera upon which the ovum is embedded 



PHYSIOLOGICAL PREGNANCY, 



47 



and which subsequently takes part in the formation of the placenta (Fig. 44). 
(3) Decidua reflexa, circumflexa or capsularis, or epichorial decidua, is not, as 
its original name indicates, reflected, but is formed by growth of the uterine 
tissues over the ovum till they meet above its surface (Figs. 45 and 47). This 




i 



Fig. 46. 



-Uterus and Ovum at Two Weeks, o, Ovum; d, decidua vera; o.i., internal 
os; s, external os. — (Leopold.) 



process of reflexion is nearly completed in the youngest human ovum, Peters 's, 
and is quite finished in from eight to twelve days after the migration of the 
ovum into the uterus. The capsule grows with the increase of the ovum until 




Fig. 



47. 



-Microscopic Section through an Ovum of about Two Weeks, showing 
Uterine Muscle, Decidua Vera and Reflexa. — (Leopold.) 



the second month, when it begins to degenerate, disappearing entirely by 
the seventh month (Fig. 49). 

Theories of the Origin of the Decidua. — There have been various theories 
concerning the decidua. In 1840 Weber and Sharpy demonstrated glands 
within it and showed it to be a hypertrophied mucosa. Friedlander's ideas 
concerning the structure of the decidua are, in general, correct. He found 



48 PHYSIOLOGICAL PREGNANCY. 

therein glands lined by high, columnar, ciliated epithelium. The decidua vera 
comprises two layers; the upper layer, or stratum compactum, consisting of 
decidual cells with gland ducts here and there, while the attached layer, or 
stratum spongiosum, is of spongy consistency, and made up of a few decidual 
cells, blood-vessels, and dilated glands or cavities. Friedlander believed that 
at the end of pregnancy the compact layer is thrown off; while there is left the 
spongy layer, which is the dilated, irregular surface usually seen. It is now 
known that the line of demarcation is somewhat deeper than Friedlander be- 
lieved. His work has been verified by Leopold and Meinert. 

The Decidual Cell. — The origin of the decidual cell, discovered by Hegar 
and Maier in the sixties, though variously explained, is now known to be the 






i \/w? , : -" .,.</ w 'is* ,/ 



WS ,-^€i s^^m 



Jill mr 



I. . ; . 




Fig. 48. — Uterus One Month Pregnant; Portion of the Compact Layer of the 
Decidua seen in Vertical Section, coagl, Coagulum upon the surface; d, d', decidual 
cells. X 445 diams. — (Minot.) 

connective-tissue cell. It is much larger than the cell of the interglandular 
substance and is often very irregular in shape. The hypertrophied decidual 
cell (Fig. 48) resembles the epithelioid cell of tuberculosis and the lutein cell. 
It also resembles the large sarcoma cell, and, according to Ruge, is the physio- 
logical type of this pathological unit. The hypertrophied decidua, the spongy 
layer in the early months of pregnancy, may look like malignant adenoma. 

Formation. — The formation of the decidua is not dependent on the presence 
of the fertilized ovum, for we find it in the extrauterine pregnancy. This 
condition is not absolutely pathognomonic of pregnancy, for the decidual cell 
is found in endometritis and membranous dysmenorrhea, in which latter affec- 
tion a cast of the uterus is thrown off. The development of the decidual cell 
from the connective tissue of the stroma of the uterus, and that of the lutein 



PHYSIOLOGICAL PREGNANCY. 



49 



cell from the connective tissue surrounding the ovum, are analogous processes. 
In the ovary they tide over the reconstruction period, while in the uterus they 
help to form the placenta, and after the birth of the child they are cast off. 



Chortonfrondosum , 




Fig. 49. — Diagram showing the Relations of the Uterus, Embryo, and Embryonic 
Structures at the Second Month of Gestation. — (After Allen Thompson.) 



l.s. 




>,.p. 



p.b. 



Fig. 50. — Segmentation of a Mammal, Bat. Two-celled Stage. Two segmentation 
spheres each having a nucleus. The dark bodies are yolk granules, s.s., Smaller 
segmentation sphere; l.s., larger segmentation sphere; z.p., zona pellucida; p.b., polar 
globule. — {After E. van Beneden.) 



Disappearance. — The decidua vera is thickest at the third month of preg- 
nancy, after which it steadily becomes thinner (Figs. 101 and 135). In early 
4 



50 



PHYSIOLOGICAL PREGNANCY. 



pregnancy the ovum does not completely fill the uterine cavity, but when this 
comes about the decidua vera is compressed and begins to atrophy, while the 
decidua reflexa comes into closer and closer contact with it, until about the 
sixth month, at which time the two deciduae cannot be distinguished. At term 





Fig. 51. — Segmentation of the Ovum, 
Rabbit. Four-celled Stage. — (After van 
Beneden) 



Fig. 52. — Segmentation of the Ovum, 
Rabbit. Many-celled or Morula 
Stage. — (After Bischoff.) 



the vera is not much thicker than the original mucous membrane. Until the 
period of fusion of these two parts of the decidua, the interval between them 
is filled with hydroperione, a mucous liquid much like the liquor amnii. During 
the later months of pregnancy the decidua undergoes a fatty degeneration that 




Fig. 53. — Segmentation of the Ovum. Sections of the ovum of the rabbit during the 
later stages of segmentation, showing the formation of the blastodermic vesicle, a, 
Showing the outer layer and the inner cell mass before the formation of a cavity; also 
the so-called blastopore; b, showing the cavity formed by the absorption of liquid; 
c, enlarged cavity; d, showing the cell mass forming a layer at one side of the thinned 
outer or Rauber's layer; ent., entoderm; ect., ectoderm; z.p., zona pellucida. — (After 
van Beneden.) 



assists in loosening its attachment to the uterus, and, as already stated, the 
greater part of this membrane is cast off during labor. Its remains are dis- 
charged with the lochia, save a very little that stays behind to assist in the 
production of a new uterine mucosa (compare Physiologic Puerperium). 

Segmentation. — In the human ovum nothing is known of the process by 



PHYSIOLOGICAL PREGNANCY. 



51 



which a single cell subdivides into many. In lower vertebrates and several 
mammals the process has been carefully followed. In the latter, the segmenta- 
tion-nucleus divides, after a short pause, into two others; while the cell-body 
also divides, thus forming two cells which again divide. These four again 
divide, and the process of subdivision is continued until a solid ball of cells is 
formed, called a morula, from its resemblance to a mulberry (Figs. 50, 51, and 
52). Such a total division of cells is called holoblastic, to distinguish it from 
meroblastic division, or such as takes place in a chick, in which a partial 
division of the egg occurs, forming a disc-like layer of cells on the surface of 
a large, undivided yolk. Such holoblastic or total division occurs in all but the 
two most primitive mammals, the ornithorrhynchus and echidna, in which 

there is a large, bird-like yolk which 
does not divide completely into 
cells. The discovery of the latter 
fact affords a key to the apparently 
anomalous condition of the higher 
vertebrates in which a true yolk 
appears a little later in development 
and increases for some weeks. In 
some of the forms observed, the cells 
of the morula are not uniform in 
appearance, larger clear cells being 
massed at one pole, smaller dark 
cells at the other. The clearer cells 




C s.c. — 



sec.c. 



Fig. 54. — Formation of the Blastoder- 
mic LAYERS IN THE MOLE IN THREE 

Successive Stages, z, Zona pellucida; 
ex., subzonal epithelium (entoderm); 
sec.c, segmentation cavity; hy., hypo- 
blast; i.m., inner mass of cells. — (Minot.) 




Fig. 55. — Formation of Gastrula, Am- 
phioxus. The entoderm, en., has begun 
to invaginate, making the segmentation 
cavity, s.c, smaller; e.c, ectoderm. — 
{After Hatschek.) 



grow and divide more rapidly, finally forming a complete envelope except at 
one point (as recorded by van Beneden) (Fig. 51), surrounding the smaller 
cells. As the morula passes by the action of cilia through the Fallopian tubes 
a liquid is formed between the two kinds of cells which increases in amount 
until there is produced a much enlarged, hollow sphere of flattened cells, within 
which and attached at one point is a group of smaller elements (Fig. 53). 
Formation of Germ-layers. — By reason of the control of conditions, which 
is possible in that animal, the formation of germ-layers has been more fully 
and frequently studied in the chick than in any other species. The following 
changes, however, have been taken from the embryology of the rabbit, which 
is tolerably well understood, because this mammal naturally has more resem- 



52 



PHYSIOLOGICAL PREGNANCY. 



blance to mankind. The concentrated mass of cells above described at the 
pole of the ovum flattens out into a disc called the blastoderm, which is seen to 
consist of two kinds of elements (Fig. 54), with two layers next to the outer 



en. 



d.g. 




tn.g. 



m.c. 



Fig. 56. — Formation of Gas- 
trula. The segmentation cavity 
has almost disappeared between 
the ectoderm, ec, and the in- 
vaginated entoderm, en., which 
lines the digestive cavity, d.g., 
or enteron. The opening of tne 
latter is the original oral opening. 
0.0. A single mesodermic cell. 
m.c, at the left at the union of 
the ectoderm and entoderm — 
(After Hatschek.) 

NT TJ JVC 




Fig. 57. — Embryonic Area of a Rabbit. Shows 
the area germinativa, a.g., primitive streak, 
p.s., and the beginnings of the medullary folds, 
m.f., with the medullary groove, m.g., between 
them; p.g., primitive groove. X 28. — (After 
Kollmann) . 



CH 



BH 



BM 




PJV 



BF 



PT 



Fig. 58. — Sagittal Section of Frog Embryo showing the Three Layers. ^ The blasto- 
pore now becomes the proctodeal opening and the neurenteric canal joining enteron 
with neural canal. — (After Gotte.) 

BF, Fore-brain; BH, hind-brain; BM, mid-brain; CH, notochord ; M, mesoblast ; NC, cavity 
of neural tube; NT, neurenteric canal; PN, pineal body; PT, ingrowth of epiblast 
which gives rise to the pituitary body ; 77, intestinal region of mesenteron ; TP, pharyn- 
geal region of mesenteron; U, proctodeal or cloacal aperture; W, liver; Y, yolk-cells. 

sphere of flattened cells, and more or less continuous with it, which together 
are regarded as the ectoderm. The cells which complete the sphere are called, 



PHYSIOLOGICAL PREGNANCY. 



53 



from their discoverer, Rauber's layer, and in the rabbit they disappear (see 



d.p. 



y.s. 



- 



a. s. 



a.c. 



Fig. 59. — Section through Early Human Ovum. 
X 24. Shows ovum embedded in the wall of the 
uterus, d.p., Discus proligerus; ec, ectoderm; m., 
mesoderm; y.s., yolk-sac; c, chorion; am., amnion; 
a.s., allantois stalk; a.c, allantoic canal. — {After 
Graf Spee.) 



y.s. 



Membranes). 

There are also cells lying 

next to the cavity which form 

the entoderm. This two- 
layered germ, though arising 

in a much modified manner, 

is properly comparable with 

the two-layered or gastrula 

stage of the amphioxus (Fig. 

55), and the cavity is also 

called the segmentation cavity. 

The blastoderm of the rabbit, 

as seen from above, soon 

takes the form of a shield, in 

the mid-line of which is seen 

the primitive streak (Fig. 57). 

In section this is found to be a thickened cord of cells in which ectoderm and 

entoderm fuse, and from the junction of which a third layer, called the meso- 
derm, extends out on either side. The 
primitive streak is considered by recent 
workers to be, in higher vertebrates, an 
elongated representative of the blasto- 
pore of the amphibia (Fig. 55), which 
in its turn represents a modified gas- 
trula mouth of the still earlier forms 
(Fig. 56). The blastopore of amphibia 
becomes covered by an unequal growth 
of cells, its last trace being in the 
neurenteric canal which connects the 
primitive enteron with the caudal end 
of the neural canal (Fig. 58). A neu- 
renteric canal with the same essential 
relations is found in higher vertebrates 
at the cephalic end of the primitive 
streak. Finally blastopore, primitive 
streak, and neurenteric canal disappear, 
leaving no trace, but they are of pro- 
found interest, since they form a com- 
mon landmark in early development 
throughout the vertebrate series, mark- 
ing the point from which the mesoderm 
takes its origin. The neurenteric canal 
is seen in a very early human ovum 
described by Graf Spee (Fig. 59). Ac- 
cording to Mall, its last remnant is 
distinct until adult structures are suffi- 
ciently developed to determine its rela- 
tive location, it being at the level of 
the first rib. This one fact shows that 

the structures derived from the head and neck are the earliest to be laid 

down, the whole of the trunk and limbs being of later formation. 



m.g. 




P-g- 






1 



•' T ■' I 



OF A 

amnion 



Human 
am., is 



Fig. 60. — Dorsal View 
Embryo. X 30. The 
nearly all removed. The yolk-sac, y.s., 
shows blood islands. The elongated 
embryo shows a medullary groove, 
m.g., the neurenteric canal, n.c, and 
the primitive streak. The abdominal 
stalk, a.s., connects it to the chorion, 
c, with its branched villi, p.g., Primi- 
.tive groove. From a wax reconstruc- 
tion. — (After Graf Spee.) 



54 



PHYSIOLOGICAL PREGNANCY. 



Formation of Primitive Organs. — The early embryology of organs has also 
been much more completely studied in the lower animals, though the differences 
that have been observed between the latter and mankind do not appear to be 
so radical in the organs as in the original layers. If the rabbit be taken as the 
type, after the three layers — ectoderm, entoderm, and mesoderm — are differen- 
tiated, the ectoderm at some little distance in front of the primitive streak 
by a process of unequal growth becomes folded in, and in a similar way at the 




m.p 




Fig. 6i. — Sagittal Section of Fig. 60. Showing in 
addition the allantoic process, the complete amnion, 
am., with a slight extension toward the chorion, c, and 
the thickening of the mesoderm, m., where the heart 
will develop, m.p., Medullary plate; h.f., heart fold; 
c.v., chorionic villi; a. s., allantois stalk; p.s., primitive 
streak; a.c, allantoic canal; y.s., yolk sac; en., ento- 
derm; v., vessels. 




Fig. 62. — Cross-section 
of Fig. 60. Shows the 
ectoderm forming the 
medullary folds and 
groove and at the right 
thinning to form the 
amnion. am., Amnion; 
ek., ectoderm; ct., amni- 
otic mesoderm; g., meet- 
ing point of somatopleure 
and splanchnopleure ; df. , 
mesoderm of yolk sac; 
b, b, b, blood vessels; en., 
entoderm; n, blastopore; 
d, cavity of yolk-sac. — 
(After Graf Spee.) 



caudal end, while at either side folds are also 
formed, until by this means the embryo is out- 
lined and somewhat raised above the general level 
of the embryonic shield. At the same time other 
folds affecting the ectoderm appear at either side 
of the axis and gradually extend caudally (Fig. 57). 

These rise above the general level (Figs. 60, 61, and 62), and as they grow 
upward, fold over toward each other until they unite to form a tube. This is 
the neural tube, and is at first in connection with the ectoderm of the general 
surface of the body, which is now called the epidermis. The first closure of the 
tube is in the neck region, the closure extending both forward and back. As 
the closure proceeds the tube is separated from the epidermis (Figs. 65 and 
66). At either side, just at the junction of the part of the ectoderm which 
is to form skin with that which is to form the neural tube, there is a thicken- 



FORMATION OF PRIMITIVE ORGANS. 



55 



ing of ectoderm which, in the form of a cord, becomes free from its attachment 
to the former. These cords come to lie on both sides of the neural tube and 
give rise to the nervous ganglia and to the sensory roots of the nerves, and 




Fig. 63. — Thompson's Specimen of Hu- 
man Embryo, showing the Dorsal 
View of the Medullary Folds much 
Elevated above the Surface. The 
caudal end was broken. The figure was 
altered by Minot to agree with facts 
discovered by His concerning the original 
drawings. A, Embryo from above; 
B, embryo from behind. — (Minot.) 




Fig. 64. — View of a Transverse Section 
of a Mole Embryo, Similar to Fig. 63, 
showing the Cephalic Expansion for 
the Eyes. Md., Medullary groove 
proper; op., optic nerve; Ec, ectoderm; 
Mes., mesoderm; En., entoderm; nch., 
notochord. 



probably also finally to the sympathetic system. Before the closure of the tube 
is complete two pockets arise from it on the two sides near the cephalic end. 
These are the first indications of the eyes (Fig. 71). As the tube closes the 




Fig. 65. — Cross-section through the Rump of a Rabbit Embryo of Eight Days and 
Three Hours. The medullary or neural tube, Md., is closed and completely separated 
from the epidermis, which is continuous with the epithelial layer of the amnion and 
chorion. At this level amnion and chorion have not separated and the folds forming 
them have not yet quite united. The chorda is separated from the entoderm. The 
myotomes, Seg., are hollow. The body-cavity, Coe., is continuous with the extra- 
embryonic cavity. There are still two aortae. An.; Cho., chorion; Am., amnion; Som., 
somatopleure ; Ch., notochord; Ent., entoderm; Spl\, splanchnopleure. — (After Minot.) 



pockets extend farther and farther outward, becoming partly constricted off 
from the tube. The outer surface of the pocket finally seems to be pushed 
inward against the inner surface until a double- walled cup (Fig. 67) is formed, 
which ultimately becomes the many-layered retina, connected with the brain 



56 



PHYSIOLOGICAL PREGNANCY. 



by the stalk which elongates and in which are developed the fibers of the 
optic nerve. The optic cup gives rise to few other parts of the eye, but the 
larger portion of them is produced from the mesoderm, which pushes in 
and around these fundamental parts (Fig. 71). At the same time that the 
optic cup is forming the ectoderm which covers it is producing an ingrowing 
pocket, which by a similar process is constricted and finally wholly separated 
from the ectoderm to form the lens of the eye, which fits into the opening 
of the optic cup (Fig. 71). The ectoderm also gives rise to the internal ear, 
which is completely constricted off, and to the external ear and the nasal 
epithelium, which form deep pockets but are never separated from the exterior. 
At the same time that the neural tube is forming, the entoderm along the 
middle line and just below the neural tube is, in a similar manner, forming 
a much smaller tube, which soon becomes solid and forms the notochord 

(Figs. 62, 63, and 64), the first trace 
of a body-axis. The notochord does 
not extend to the cephalic tip of the 
neural tube but stops at the hypophysis 
(Figs. 66 and 71); that is, near the level 
of the sella turcica of the adult skull. 



am. 



h.c. 



t.c.r. 





Fig. 66. — Sagittal Section of a Rabbit 
with 8 to 12 Myotomes. Shows the neural 
tube hollow and beveled to form the fore- 
brain, f.b.; the chorda, c, bent and touch- 
ing the hypophysis, h.c; the blind end 
of the entoderm, en., coming in contact 
with the ectoderm to form the oral 
plate; the continuation of the ectoderm 
to form the amnion, am.; the heart, 
h., prominent and just below the mouth- 
cavity, m.c. t.c.r., Trabecular cranii of 
Rathke; f.g., foregut. — (After Keibel.) 



Fig. 67. — Section through the Develop- 
ing Eye of a Human Embryo (10.2 mm. 
Long) . Shows the open stalk connected 
with the mid-brain; the double-walled 
optic cup; the vesicle of the lens cut off 
from the ectoderm, ec; and mesoderm 
growing in to form the cornea, c, vitreous, 
etc. m., Mesoderm; v.h., vitreous humor; 
r.l., retinal layer; p. I., pigment layer; s. 
and c, sclera and chorioidea; /., thala- 
mencephalon; c.o., conus opticus; e., epen- 
dyma. — (After Kollmann.) 



The chorda and its cephalic end form landmarks throughout the vertebrate 
series and from very early stages of development. In mammals it becomes 
insignificant, as it is enclosed in the vertebral column. The entoderm at first 
lines a simple, unconstricted yolk-sac (Fig. 59), but by a growth similar in 
some respects to the formation of the neural tube it gives origin to a blind tube 
at both the cephalic (Fig. 66) and the caudal regions. Then by lateral in- 
growth or constriction a continuous tube, the alimentary canal, is formed, and 
the union with the yolk-sac from which it was constricted becomes relatively 
smaller until there is a mere stalk, vitelline stalk (Figs. 60 and 71). In mam- 
mals the yolk-sac grows for a time, and there is formed within it a true yolk; 
but as the membranes come to perform their nutritive functions the yolk loses 
its historical importance in nourishing the embryo and soon becomes so small 
in relation to the surrounding structures that it is easily overlooked. Each 



FORMATION OF PRIMITIVE ORGANS. 



57 



of the blind tubes of the entoderm above mentioned comes in contact with an 
ingrowing pouch of ectoderm. The double layer so formed of ectoderm and 
entoderm (Fig. 66) breaks down, thus forming the openings from the alimentary 
canal to the exterior, the mouth (Fig. 71) and the anus. By a process of 
formation of pouches, modified sometimes into solid outgrowths or tubes, the 
entoderm of the alimentary canal gives rise to the lungs, liver (Fig. 71), pan- 
creas, and the special glands of the enteron. The mesodermic sheet or layer 
arises at the primitive streak and first pushes for- 
ward at either side of the middle line but not 
crossing it. The portion lying next the noto- 
chord becomes segmented. Each of these seg- 
ments at some stage is hollow and is called 
a myotome (Fig. 65). That portion of the myo- 
tomes which lies next to the ectoderm fuses with 
it to form a portion of the skin, while the re- 
maining part undergoes very extensive growth 



vagus nerve 

external 
carotid 

internal 
carotid, 



recurrent 
laryngea 



nerve 




rig?U 
subclavian/ 



inriorriincde 
artery 



vertebral 

arch of 
aorta 

,left . 
subclavian 

diccius 
arteriosus 



pulmonary 
trunk 



ascending 

aorta 



a£>rta< 



Fig. 68. — Diagram showing the Destination of the 
Arterial Arches in Man and Mammals. — {Modified 
from Rathke.) 




Fig. 69. — Scheme of the De- 
velopment of the Chief 
Veins of the Body. — (Quain.) 



and modification to form the muscles of the body and limbs, and an important 
part of the mesenchyma from which the supporting and bony framework of 
the body is developed. That portion of the mesoderm which does not take 
part in the formation of myotomes, and which lies at the sides of the latter, 
becomes early divided into two layers, one of which unites with the ectoderm 
to form the somatopleuric or parietal layer, — which gives rise to the body- 
wall, the amnion and chorion, — while the other, uniting with the entoderm, 



58 



PHYSIOLOGICAL PREGNANCY. 



forms the splanchnopleuric or visceral layer, which gives rise to the alimen- 
tary canal and its derivatives (Figs. 62, 63, and 64). It is the mesodermic 
portion of the latter which gives rise to the muscles and connective tissue of the 
alimentary canal. 

The space formed by the separation of these two layers of mesoderm is the 
body-cavity or ccelom. At 

first, in man, it seems to be mi - 

separate from the extra-em- / 

bryonic ccelom (Fig. 62), but 

soonbecomes continuous with tJl - . ' ^fr 

it, as in the rabbit (Fig. 65). 
Later this connection is lost 
by the growth of the body- 
walls to unite around the 
umbilical cord. The body- 
cavity proper is divided by 
the gradual growth of the 
diaphragm into abdominal 
and thoracic cavities. The 
thoracic cavity is further 
divided into the pericardial 
and the two pleural cavities. 
All the supporting and con- 
nective tissues, as bone, car- 
tilage, and the muscles and 
blood-vessels, take their origin 
from the mesoderm ; but while 
the problems involved in a 
full consideration of the me- 



ch. 



b.c. - — 





o.m.v. 



o.m.v. 



Fig. 70. — The Developing Fore- 
limb, SHOWING THE BUD EX- 
TENDING and Fingers Form- 
ing. A, At four weeks; B, at 
five weeks ; C, at seven weeks ; 
D, at nine weeks. — (After His.) 



u.a 



Fig. 71. — Human Embryo at Third Week. The left 
body-wall or side has been removed, so that the 
neural canal and gut are exposed. The left wall 
of the anterior end of the gut and the still very 
broad vitelline duct have also been removed, th., 
Thalamencephalon ; o.v., optic vesicle; c.h., cerebral 
hemisphere; b.c, branchial clefts; t.a., truncus 
arteriosus; /., lung; a., auricle; li., liver; o.m.v., 
omphalo-mesenteric vein; v.d., vitelline duct; t., 
tail; u.a., umbilical artery; mi., midbrain or mesen- 
cephalon; m., medulla; d.a., descending aorta; c, 
chorda; e., esophagus; s., stomach; i., intestine. — 
(After His's model.) 



soderm and ccelom are fundamental in character, they are very complex and, 
moreover, have not been satisfactorily worked out in their finer details. (For 
the heart and vascular system, see sections on Nutrition and Circulation.) 

The urogenital system is derived from a cord of tissue lying between the 
myotomes and the ccelom (Fig. 65). This early forms the Wolffian duct, 








Fig. 77. — End of 2d month (626. 
day) (nat. size). 



V 



\ 



A -**c 






\ 



J* 




Fig. 72. 


Fig. 73- 


Fig. 74- 


Fig. 75- 


Fig. 76. 


12th day 


21st day 


30th day 


34th day 


6\ week 


(nat. size). 


(nat. size). 


(nat. size). 


(nat. size). 


(nat. size) 



% 



i 1 



Fig. 78. — End of 3d month 
(nat. size). 



Fig. 79. — End of 4th month (nat. size), 



Figs. 72 to 79. — Natural size and Development of the Human Embryo in the First 

Four Months of Pregnancy. 

(Figs. 72 to 77 are from His, and Figs. 78 and 79 are from Bumm's fresh fetuses.) 



59 



60 



PHYSIOLOGICAL PREGNANCY. 



which gives rise to tubules forming the primitive excretory apparatus, the 
mesonephros or Wolffian body. This structure projects far into the ccelom 





^-J^f 



Figs. 80, 8i, 82, 83. — Fetal Skulls of the First Third of Pregnancy (Two-thirds 
Natural Size). — (Author's collection.) 

and its mesothelial covering cells which give rise to the Miillerian duct, and 
to the ova or zoosperms, the essential parts of the ovary or testis. The meso- 




Figs. 84, 85, 86. — Fetal Skulls of the Middle Third of Pregnancy (Two-thirds 
Natural Size). — (Author's collection.) 

nephros disappears gradually, but its duct at the caudal end gives rise to the 
duct and tubules of the true kidney. In the male it produces the vas deferens. 



V 




Figs. 87 and 88. — Fetal Skulls of the Ninth and Tenth Months of Gestation 
(Two-thirds Natural Size). — (Author s collection.) 



In the female the Mullerian ducts are transformed into the Fallopian tubes 
and caudally, by their union, into the uterus and vagina. The limbs arise as 
mere pads of indifferent mesodermic tissue covered by ectoderm. Into them 



GERM-LAYER; ORIGIN OF MEMBRANES. 61 

gradually extend outgrowths of the myotomes producing muscles and carrying 
with them the vessels and nerves which have already joined them. A part 
of the mesoderm is condensed in rod-like forms. The connective-tissue cells 
are transformed into cartilage in those portions of the rods which are to form 
the bones. Where the joints are to be, the condensed connective tissue persists, 
forming amphi-arthrodial joints. The true synovial joints are developed later 
by a solution of the connective tissue between the ends of the cartilages. The 
hands are formed gradually from mere pads and the fingers are at first webbed 
(Fig. 70). 

In the main outlines human differentiation of organs is like that of the rabbit, 
as shown by the fact that the selected illustrations are mostly human; but in 
one important particular the distinctively human development differs from 
that of the rabbit, the body being outlined from outlying portions at a later 
stage relatively than in that animal. In this respect it more nearly resembles 
the mouse (see Membranes, pages 53 and 54). 

Tissues or Organs Derived from Each Germ-layer. — Ectoderm: (1) Ectodermic 
layer of chorion and amnion. (2) Epidermis with appendages (hair and nails); 
the epithelium of (a) all skin glands including the mammary; (b) the stomodeal 
portion of the mouth, including the salivary glands and the enamel of the teeth; 
(c) the nasal passages, upper part of the pharynx, and the hypophysis; (d) the 
proctodeal portion of the alimentary canal; (e) the crystalline lens and the ex- 
ternal ear. (3) The whole of the nervous system, brain, spinal cord, nerves, 
ganglia, and epithelial portions of the organs of sense (retina, internal ear, olfac- 
tory, taste and tactile organs). Mesoderm: (1) The urinary and genital organs, 
except the lining of the bladder and urethra. (2) The skeleton and all support- 
ing connective tissue. (3) All muscles, both striated and unstriated. (4) (a) 
The epithelium of the vascular and lymphatic systems and of serous cavities 
derived from the ccelom or arising in joints; (6) blood and lymph. Entoderm: 
The epithelium of the alimentary canal (exclusive of the stomodeum and proc- 
todeum) with that of its derivatives, Eustachian tube, thymus, thyroid, lungs, 
liver, pancreas, bladder, urethra, urogenital sinus, and all the small glands and 
tubules, together with the rudimentary allantois and the yolk-sac belonging to 
the membranes. 

Origin of Membranes. — The membranes are the extra-embryonic portions 
of the ovum which serve to aid in its protection and nutrition. Because of the 
ease and frequency of the study, the most familiar type of membrane formation 
has come to be that of birds. In these animals the folds of united mesoderm 
and ectoderm or the somatopleure (see above), which have been tucked in all 
around to outline the embryo, rise up outside the embryonic region until, like 
the medullary folds, they unite over the back of the embryo to form a closed 
sac. Synchronous with the upward growth a still more peripheral portion 
of the splanchnopleure continues around the ventral portion until a union takes 
place. This results in the formation of a continuous sac enclosing both embryo 
and yolk-sac. The portion of the membranous sac dorsal to the embryo is now 
composed of two layers connected in the middle line. The line of junction 
breaks down, and there results an inner closed sac, the amnion, covering in the 
dorsal part of the embryo and formed by an extension of its body- wall; and 
an outer closed sac, the chorion, which encloses not only the amnion with the 
embryo, but the yolk which depends from the ventral side of the latter. It 
also includes the white of the egg and lies next the shell. From the caudal end 
of the entoderm grows out a sac, the allantois, covered with the splanchnopleuric 
layer of mesoderm and carrying with it blood-vessels from the heart. The 



62 



PHYSIOLOGICAL PREGNANCY. 






4 



—d 



vch- 





ORIGIN OF MEMBRANES. 



63 



allantois expands until it comes in contact with the chorion, where it brings 
its blood-vessels close to the exterior, thus serving as an organ of respiration. 
In some mammals, as the rabbit, horse, pig, and cow, a modification of the 
above method of membrane formation occurs which is in the nature of an abbre- 
viation of the process. As stated above, in such forms the ovum consists at 
the end of segmentation of an outer Rauber's layer, with a nodule of cells at 
one pole (Fig. 53). The cells at the pole multiply and spread out in the form 
of a plate which gives rise to the three layers, the ectoderm becoming continuous 
with Rauber's layer. The entoderm grows around inside Rauber's layer and 
forms the hollow yolk-sac. The splanchnopleuric layer of the mesoderm never 
completely invests the yolk (Fig. 65), as it does in the chick; it forms the amnion 



VnlJcsac 



Embryo 



slofbarfrofembn o 



r ut/ire intestinal 
canal. 




[inbilical Jeside 
'-. — - -_c_ Cari ft- of Amnion 




ms 



Embryo 



DoublefoMofblas/odernac BadofEmbryo 

membr/T/ic rising to form 

Yneanviion. 




Fig. 90. — Schematic Representation of Fig. 91. — Schematic Representation of Em- 
Formation of Fetus and Amnion. bryo, Amnion, Chorion, and Umbilical 

Vesicle. 

outside the embryo and a chorion which separates from the amnion (Fig. 65); 
the principal modification consisting in the fact that as the mesoderm does not 



Fig. 89. — Five Schematic Figures Illustrating the Fetal Membranes; all these, 

with the Exception of the Last Embryo, are Represented in Longitudinal 

Section. — (After Koelliker.) 

1, Blastodermic vesicle with zona pellucida, segmentation cavity, germinal area, and 
site of the embryo. 2, Blastodermic vesicle with developing yolk-sac and amnion. 3, 
Blastodermic vesicle with closing amnion and protrusion (or budding) of the allantois. 
4, Blastodermic vesicle with chorionic villi, larger allantois, and embryo with oral and anal 
orifices. 5, Blastodermic vesicle showing vascular allantois in contact with the chorion 
and penetrating the villi of the same ; an umbilical cord is indicated ; the yolk-sac is atrophic 
and the amniotic cavity is increasing in size. The ectoblast is represented in yellow, the 
visceral mesoblast and the vascular layer of the allantois and yolk-sac are red, the ento- 
blast green. The zona pellucida in Figs. 1 to 3 is represented in black, as are also: Fig. 1, 
the entire middle germinal layer; Figs. 2,3, and 4, the parietal mesoblast of the amnion; 
Figs. 2 to 5, the mesoblast in the neighborhood of the embryo, with the exception of the 
splanchnopleure and heart. 

a, Place at the origin of the embryo showing thickening of the wall of the germinal 
vesicle; ac, amniotic cavity; al, allantois; ar.i, amnion; ar, commissure of the amnion; as, 
amniotic fold of the umbilical cord; vs, vascular layer of the allantois; vv, vascularized 
chorionic villi; d, zona pellucida; dd, site of the gut lined with entoblast; this site originates 
from a portion of the inner layer of the blastodermic vesicle (later the epithelium of the 
yolk-sac); vd, vitelline duct; e, embryo; h, region of the heart; gc, segmentation cavity 
which later becomes Ys, the cavity of yolk-sac; cs, head-fold of the amnion; m, thickening 
of the middle layer of the blastodermic vesicle which is a part of the site of the embryo 
m', at first extending no further than the germinal area; ex, original space between amnion 
and chorion (exoccelom) ; ch, chorion, as yet without villi (serous covering) ; cs' , tail-fold 
of the amnion; st, region of the sinus terminalis; u, urachus (allantoic stalk); vl, anterior 
body-wall in the region of the heart. 

In figures 2 and 3 the amniotic cavity has, for the sake of clearness, been drawn too 
large. The cavity of the heart has everywhere been represented too small and many 
details, more particularly the body of the embrvo. have, with the exception of figure 5, 
simply been shown schematically. 



64 



PHYSIOLOGICAL PREGNANCY. 



extend to the ventral limit, the chorion composed of ectoderm and mesoderm 
is not completed on the ventral side. This interval is completed by the simple 
layer of ectoderm forming Rauber's layer. The modification is still further 
emphasized by the atrophy and disappearance of the cells of this layer. The 
facts just stated have given rise to many ill-founded theories with regard to 
human development; thus, Rauber's layer was supposed to have no relation 



Chorion /rondosu/rv 

Jfeadof\ N 
Embryo )% 



[Tmbilical Vesicle (AtroptyinyJ 




Jntestinal 
CanctZ. 
ChorionZeve 

Fig. 92. — Schematic Representation of Early Embryonic Structures. 

to the true ectoderm, and as the entoderm seemed to come to the surface, it was 
supposed that there was a so-called "inversion of the germ-layers." 

Another modification of the membrane-formation which has been used to 
explain the condition in man is well illustrated in the mouse and some other 
rodents. The heap of cells at the pole first differentiates off a few entodermal 
cells which multiply and form a layer. A cavity then appears in the ectodermic 
portion of the mass of cells which enlarges so greatly as to form a sac nearly 





Fig. 93. — Human Ovum Twelfth to Thirteenth Day. — (Reichert.) 

covered by the ectodermic layer, the whole extending far into the interior of 
the outer or Rauber's layer of the ovum. The embryo is formed at the deepest 
portion of this invagination. The amnion is produced by the growing together 
in an hour-glass-like formation of the invagination over the back of the 
embryo; the remaining portion next the original implantation of the heap of 
cells becoming the chorion and finally a part of the placenta. Here, too, the 
remaining portion of the ectoderm in Rauber's layer does not apparently become 
a part of the chorion. Contrary to the condition in the chick, rabbit, and many 



THE AMNION; THE LIQUOR AMNIL 65 

other mammals, the allantois of the mouse does not form a large pouch of ento- 
derm, but is a small tubular invagination of the yolk-sac. It is, however, covered 
by mesoderm, which continues as a sheet over the chorion and carries the blood- 
vessels of the embryo to the placenta, where the blood is aerated. 

In Peters's embryo, the youngest human specimen studied, it is seen that 
the conditions are not as in the chick, with early formation of embryo and 
subsequent differentiation of membranes; nor as in the rabbit, nor even quite 
as in the mouse. The membranes in Peters's embryo have been developed 
precociously. The chorion is a completely closed sac with a mesodermic lining, 
such as occurs quite late in the chick. There is no sign of the disintegration 
of the outer ectodermic layer, as in the Rauber's layer of the rabbit, but later 
stages (according to Mall) indicate that it becomes transformed into the syncy- 
tial layer of the chorion (q. v.). The amnion is also a closed sac with the un- 
differentiated embryo, a simple thickened plate of cells, lying in its deepest 
portion, thus having a strong resemblance to the early condition in the mouse. 
The yolk-sac is also closed and is larger than the amnion, but is not constricted 
with any indication of an alimentary tract, as would be the case in the chick 
at a similar stage of development with reference to the mesoderm. The latter 
has, indeed, attained a remarkable development. It has entirely invested the 
yolk-sac forming the splanchnopleure, while the somatopleure is represented 
by the amnion and the chorion completely invested by the mesoderm before 
there is an indication of the formation of myotomes. Whether the amniotic 
sac becomes hollowed out of a solid mass of cells, as seems to be the case in the 
mouse, or whether there is only a division of the amnion from the chorion, such 
as occurs in the rabbit (as surmised by His and Nagel), although taking place 
relatively earlier, cannot be determined without further investigation. In Graf 
Spee's embryo (Figs. 60 and 61), and in an ape examined by Selenka, an appear- 
ance is found which points to the latter conclusion ; since the amnion in these speci- 
mens has a diverticulum pointing toward the chorion, as though just constricted 
off therefrom. The important point in this connection is that the amniotic sac 
never separates completely from the chorion as with the rabbit, but remains 
connected with it by a broad band of mesoderm. In the next later stages of 
human embryos it is found that a small diverticulum of the yolk-sac extends 
into this mass of mesoderm, which has become relatively smaller, forming the 
stalk which with further development becomes the umbilical cord. Although 
a true allantois — in the sense that it occurs in the chick and many mammals 
— is not present, the mesodermic layer of that organ may be said to exist; since 
the blood-vessels, when they arise, pass by way of this allantoic rudiment through 
the abdominal stalk to the chorion. To sum up, this earliest human ovum, 
before an embryo has even been outlined, has membranes of a stage of develop- 
ment corresponding to a much later stage in the chick, a closed chorion, a closed 
amnion, a closed yolk-sac. The essential difference is that there is no free allan- 
tois containing an extensive entodermic cavity, and that the mesoderm con- 
nects the embryo with the chorion from the earliest stages and not secondarily. 

The Membranes at Term. — At term the fetus is surrounded by three mem- 
branes, two of which are of fetal and one of maternal origin. Their order, from 
within outward, is: amnion, chorion of fetal origin, and decidua reflexa and 
vera of maternal origin. 

The Amnion. — As seen above, the amnion is the innermost of the fetal mem- 
branes. At first it encloses only the dorsal part of the embryo, but with growth 
and closure of the body- wall around the umbilicus, it completely invests the 
embryo except that the cord passes through it. It is continuous with the fetal 
5 



66 



PHYSIOLOGICAL PREGNANCY. 



X 



a.s. 



p.m. 



epidermis at the umbilicus (Figs. 59, 60, 6 1, 62, 89, 90, 91, and 92). It consists 
of two layers, one of flattened cells derived from the ectoderm and continuous 
with the epidermis, the other of connective-tissue cells and fibers, mesoblastic 
in origin. The enclosed space constitutes the true amniotic cavity or sac, and 
its chief function is the secretion of liquor amnii. At first the amnion, as com- 
pared with the embryo, is quite large. Then the embryo grows more rapidly 
and the amnion closely invests it ; and finally at the second month a more rapid 
growth of the amnion takes place, which ultimately results in a close relation- 
ship between it and the chorion. As long as a cavity exists between amnion 
and chorion it is sometimes called the false amniotic cavity and is filled with 
a liquid somewhat similar to the amniotic fluid. At birth the bag of waters 
consists of the amnion and part of the chorion. Sometimes this is not ruptured 
until after the head is born. 

Liquor Amnii. — The amniotic fluid contained in the amniotic sac is some- 
what variable in quantity, the 
JMu, average being about a liter, or 

quart. Of this, nearly one- 
half is formed during the last 
three lunar months. At times 
this fluid is very scanty, so that 
it interferes with the growth of 
the fetus, and causes its pre- 
mature expulsion. There is 
on record a case in which, in 
the absence of a normal supply 
of liquid, ulcers were formed 
on the knees and ankles of a 
fetus, due possibly to friction. 
Many other deformities have 
been found to be correlated 
with the same condition. 
When its amount is exces- 
sive, the condition is called 
hydramnios, in which many 
quarts of fluid may be present. 
The amniotic fluid is alkaline 
in reaction. Its greatest bulk 
— nearly 99 per cent. — consists of water, in which are found albumin; creatin; 
epithelial cells from the fetal skin, bladder, and kidneys; sebaceous material; 
urea and several inorganic salts (phosphates, chlorides) ; as well as many other 
constituents. Its specific gravity varies between 1.0005 and 1.0082. It is 
generally opaque, white in color, although this may change from the presence of 
unusual ingredients, meconium giving it a dark brown tinge, while a macerated 
fetus colors it red. It has a heavy and characteristic odor. Keim has found 
that the freezing-point of this fluid is higher at term than that of the maternal 
or fetal blood-serum. This indicates an intrinsic tendency to absorption. Its 
origin is a moot question. The theory that it consists chiefly of fetal urine is 
disproved by chemical analysis, only a small part arising from this source. The 
fetal tissues contribute a small portion by exudation. The greater part is of 
maternal origin and the result of transudation through the placenta. The 
investigations in regard to the two sources of the amniotic fluid have been as 
varied as they are interesting As to the excretion of urine by the fetus, there 



y.s. 




•-•'"> 



Fig 



94. 



Ruptured Human Ovum Fifteenth to 
Eighteenth Day. Amnion has been opened, a.s., 
Allantois stalk; p.m., parietal mesoblast; y.s., 
yolk-sac; a., amnion; h., heart. — (Coste.) 



THE AMNION; THE LIQUOR AM NIL 



67 



seems to be undeniable evidence, more than three pints of this excretion having 
been found in the fetal bladder. After the communication between the bladder 
and the exterior of the body is completed through the agency of the urethra, 
there is from time to time a passage of the renal secretion from the fetus into 
the amniotic fluid. At just what stage of fetal development this occurs has 
not yet been decided. This prenatal urine is very poor in coloring-matters, 
as may be seen from the specimens collected soon after birth. Another theory 
supposes that the fetal skin is the source of this fluid, and there has, indeed, 
been noted in several cases a connection between affections of the fetal skin 
— in one instance extensive nevi — and hydramnios. The view that much of 
the liquor amnii has a maternal source is substantiated by the results of numerous 
experiments. Tuntz, after the injection of sulphindigotate into the veins of 
pregnant rabbits, recognized the reagent in the liquor amnii by its blue coloring- 
matter, while there was no trace of it in the fetal kidneys. Experiments with 







J«L 



i I 




Fig. 95. — Isolated Terminal Branch of 
Villus from the Chorion of an 
Embryo of Twelve Weeks. — (Minot.) 



Fig. 96. — Chorionic Villi at Five Months. 

— {Minot.) 



other substances — e. g., iodin, salicylic acid, and potassium ferrocyanid — have 
been made. Chloroform administered to the mother in labor has been demon- 
strated later in the umbilical circulation, so that it probably exerts an an- 
esthetic influence on the fetus. However, the endeavor to introduce such 
substances as fat, vermilion, and india ink into the fetal circulation by admin- 
istering them to the mother has had doubtful success, positive results being 
undoubtedly dependent on injury to the blood-vessels. 

There has been much discussion as to the passage of formed elements, such 
as pathogenic bacteria, from the mother to the fetus; and various opinions 
are held on the subject. Certain substances taken by the mother are found 
later in the liquor amnii, even when the fetus is dead — showing that the latter 
took no part in the process. Also cases in which the product of conception is 
early destroyed exhibit an amount of amniotic fluid corresponding to the age 
of the ovum, and not to the development of the embryo. 



68 



PHYSIOLOGICAL PREGNANCY. 



Functions. — The functions of the liquor amnii are varied, being chiefly, 
however, protection for mother and child. It saves the uterus from the in- 
jurious effects of fetal movements. It distends that organ, and thus allows 
a certain freedom of movement to the fetus, and by the prevention of adhesions 
between the amnion and child it lessens the chance of development of mon- 
strosities as well as intrauterine amputations and other abnormalities, and 
prevents any harmful pressure by the uterine walls. The amniotic fluid has 
a specific gravity near enough to that of the fetus to lessen greatly the muscular 
efforts in its movements. It protects the fetus from external violence and 
maintains for it an equable temperature It receives and dilutes the fetal 
secretions and, according to some authorities, serves as a source of nourishment 
to the fetus. This last suggestion has little foundation, although the presence 
of lanugo and epithelial cells in the meconium shows that the amniotic fluid 
has been swallowed. It is quite probable, however, that it supplies to the fetal 
tissues a large proportion of the water which they possess before birth, in order, 
according to Preyer, that they may be able to absorb from the blood of the 
umbilical vein the albumin and salts which it contains. Finally, the hydraulic 
action of the amniotic fluid is most valuable in labor. It forms a veritable 

water- wedge, and serves by its 
downward pressure to dilate 
the circular muscle bands of 
the os uteri; and after being 
released from the amniotic sac 
it acts as a lubricant to the 
birth canal. 

The Allantois— The allan- 
tois in many mammals is a 
diverticulum of the caudal 
part of the alimentary canal, 
which carries with it the 
splanchnic layer of the meso- 
derm until contact is made 
with the chorion, thus forming 
a large sac containing fluid. But in man the entodermic diverticulum is a mere 
rudiment (Fig. 61) which can be traced along the umbilical cord for some distance 
but does not form a free sac. A mesodermic layer, however, perfectly analogous 
to that of other mammals, does connect the caudal end of the embryo with the 
chorion and serves to carry the blood-vessels from the embryo to the chorionic 
villi. This mesodermic layer, as seen above, is precociously formed. As in 
other mammals, the proximal portion of the allantoic rudiment forms the urinary 
bladder and the urachus which becomes one of the ligaments of the latter. 

The Chorion. — There is probably no organ in the human fetus which has 
been the subject of such false conceptions as the chorion. It is defined by Minot 
as follows: "The whole of that portion of the extra- embryonic somatopleure 
which is not concerned in the formation of the amnion." As shown above, 
the young human ovum already has a chorion with a mesodermic lining 
(Fig. 59). It is covered by villi, solid outgrowths of the epithelial layer which 
show slight cavities at their bases into which the mesoderm protrudes. The 
villi extend into the uterine mucous membrane in such a way as to indicate 
that epithelium, glands, and walls of blood-vessels in their path have been dis- 
integrated and not merely pushed aside; that is, they protrude freely into the 
maternal blood. In the somewhat later stage shown in Reichert's ovum (Fig. 




Fig. 97. — Chorionic Villi at Full Term. — {Minot.) 



THE ALLANTOIC; THE CHORION. 



69 



93) the villi are grouped in a band, leaving the two flattened poles of the ovum 
bare. Still later the villi become hollow with two distinct layers of epithelium, 
and soon are penetrated by blood-vessels which have entered the mesoderm 
of the chorion. The simple club-shaped villi of the early ovum soon begin to 
degenerate on the side next to the decidua reflexa until in this part the chorion 
is smooth, chorion lave (Figs. 49 and 102). On the smaller area next the decidua 
serotina, the villi become greatly enlarged and complexly branched, the blood- 
vessels of the embryo following the ramification. This part of the chorion is 
called the chorion frondosum, and becomes the fetal portion of the placenta 
(Figs. 49 and 98). 

The outer layer of the epithelium of the villi undergoes a peculiar modifica- 
tion. The cells, rapidly developing, do not entirely separate, but form a syn- 
cytium * with numerous nuclei. As seen from the first, this has a destructive 
effect on the uterine mucosa and blood-vessels (Fig. 59). On account of the 




Fig. 



-Unruptured Human Ovum of about Third Week, 
X 2 J. — (Author's case.) 



showing Chorion. 



theoretical objections to the idea of contact of fetal epithelium and maternal 
blood with no intervening maternal structures, the syncytium has been considered 
by many as an altered maternal structure covering the blood sinuses. All 
the evidence now accumulating seems to point in the direction above stated, 
that it is a fetal structure ; and the chorionic villi, although bathed in maternal 
blood, separate the latter from the embryonic blood. The villi assume different 
characteristics at different stages of development. At the stage of formation of 
the placenta at the third month they are irregular, short, and thickset (Fig. 95). 
Later they are more regular and the angle formed by the junction of their 
branches with the parent stem is more obtuse (Fig. 96). At the close of preg- 
nancy their arrangement is more regular, while the branches are less densely 

* Syncytium: (1) A single cell having many nuclei; (2) a structure composed of epi- 
thelial cells, forming the outermost fetal layer of the placenta, and lying between the decidua 
and chorionic villi over the layer of Langhan. 



70 PHYSIOLOGICAL PREGNANCY. 

crowded and far more slender (Fig. 97). Knowledge of the appearance of 
the villi is most important, since the existence of pregnancy is positively con- 
firmed by their microscopic detection in suspicious discharges from the vagina. 
The embedding of the villi in the decidua is never very intimate, and through- 
out their course of development they can be extricated with very little difficulty. 
A large number of the villi do not penetrate the decidua to any depth; those 
which are intimately joined to it are called the anchoring or fastening villi. 

The Placenta. — The placenta is the essential nutritive and respiratory organ 
of the fetus. It results from the union of the chorion frondosum, q. v. (placenta 
fcetalis), and the decidua serotina (placenta maternalis). Formation: In addi- 
tion to the growth of the chorionic villi, q. v., there are extensive changes in 
the placental region of the decidua, which also proliferates and forms septa; 
these, growing down between the chorionic villi, sometimes reach the surface 




Fig. 99. — Ovum of Fig. 98 Cut Open, showing Embryo and Amnion. X 2%. 

(Author's case.) 



of the chorion. It is only at the margins of the placenta that the decidual septa 
are well marked. Interesting and important formations in the placenta are 
the intervillous spaces. The decidua vera is abundantly supplied with a net- 
work of blood-vessels which, as we have already seen, are entered by the grow- 
ing villi of the chorion. With continued growth these open capillaries become 
the intervillous spaces, which are really large sinuses or lacunae of maternal 
blood, the endothelial cells of which have disappeared. As a result of this 
change the branched chorionic villi extend freely into an almost continuous 
sinus of maternal blood which is bridged by villi (anchoring villi) the tips of 
which are embedded in the decidua. The little curling arteries, so called, which 
are derived from the maternal blood-vessels, run along the decidual septa and 
empty into the sinuses near the chorion. The maternal veins start from the 
bases of the septa, and thus the circulation is maintained through the sinuses. 
Structure: The mature placenta is a flat, round or oval, sponge-like body 



THE PLACENTA; THE UMBILICAL CORD. 



71 



which measures from 6 to 8 inches (15 to 20 cm.) in diameter and 0.8 to 
1.2 inches (2 to 3 cm.) in thickness at the central point, while the margin is 
about 0.2 inch (0.5 cm.) in thickness. Its weight is about a pound (500 
grams). After expulsion the uterine or maternal surface is dark red and 
granular, invested by a grayish, transparent membrane consisting of the super- 
ficial layer of the cells of the decidua serotina, and is marked by numerous 
ridges and lines which divide it into irregular lobes called cotyledons. These 
number from sixteen to twenty. On this surface of the separated placenta 
are tags of tissue corresponding to the decidual layer. The placenta, when 
detached from its bed, shows the line of demarcation in the spongy layer 
{q. v.) of the decidua. The fetal surface, smooth and shining, is covered by 
the amnion, and the umbilical cord is attached to its center. The bulk of the 
organ is spongy in character and consists of the tufts of chorionic villi and the 
intervillous spaces which are divided into cotyledons, above mentioned, by septa 
of connective tissue. After the separation of the placenta from its maternal 
site tags of decidua and chorion hang from the latter. Around the peripheral 
margin of the placenta is sometimes seen 
a circular vein, the "circular vein of the 
placenta." Site:* The placental site, as 
has already been described, is at the 
junction of the chorion frondosum and 
decidua serotina, which generally takes 
place near one of the tubal orifices, 
although the organ may be found 
attached to any point in the cavity of 
the uterus. As a rule, it faces the ven- 
tral surface of the fetus. 

The Umbilical Cord.— The umbilical 
cord is a means of communication be- 
tween the fetal and maternal organisms. 
It is also called the funis, funicle, or navel 
string. Origin and development: In the 
human ovum the mesodermic connection 
of the amnion with the chorion, includ- 
ing the rudimentary allantois, is called 
the abdominal stalk (Figs. 59 and 60). 

With the growth of the body- wall and the extension of the amnion this stalk, 
together with the stalk of the umbilical vesicle, and the blood-vessels which 
unite the embryo with the chorion, become invested by a continuation of the 
somatopleure, the whole forming the umbilical cord (Fig. 94). The umbilical 
vesicle itself is never included within this cord (Fig. 94), but extends freely 
beyond it, and by the fourth week becomes inconspicuous. Structure and 
vessels: The epithelium of the cord consists not of a single layer but of several 
layers of stratified epithelium, continuous at the proximal end with the epi- 
dermis and at the distal end with the amniotic epithelium covering the 
placenta. The cord is not covered by the amnion throughout its entire 
extent, for this latter structure is always separate from the cord proper. A 
gelatinous substance, Wharton's jelly, protects the cord vessels perfectly from 
harmful pressure. It is derived from the mesodermic layer of the abdominal 
stalk. The gelatin has an irregular distribution, being thicker in some parts, 

* For the exact location of the placenta, see Diagnosis of Pregnancy, and Cassarean 
Section. 




Fig 



100. — Human Ovum and. Embryo 
at Four Weeks. X 2 and reduced. — 
(Schultze.) 



72 



PHYSIOLOGICAL PREGNANCY. 







m 




m 





Fig. ioi. — Complete Ovum and Decidua Vera of about the Sixth Week. Shows 
smooth and rough surfaces of decidua vera and chorion. Photographed under water. 
X 2. — {Author's case.) 



THE PLACENTA; THE UMBILICAL CORD. 



73 



where it forms the so-called false knots in the cord. This peculiar substance 
consists in great part of embryonic connective tissue, and is abundantly 




Fig. 102. — Ovum of Fig. ioi Opened; shows Chorion Removed Except at Site of Rudi- 
mentary Placenta above and to the Right; Amnion. Liquor amnii, and Embryo 
with Rudimentary Umbilical Cord. x i\. — {Author's case.) 




Fig. 103. — Ruptured Human Ovum at Eight Weeks. X 2. 

u.c, umbilical cord. — (Schultze.) 



c, Chorion; a, amnion; 



supplied with branching cells, the protoplasmic processes of which freely anas- 
tomose. The vessels of the funis are originally two arteries and two veins 



74 



PHYSIOLOGICAL PREGNANCY. 




Fig. 104. — Amnion, Liquor Amnii, Embryo, and Umbilical Cord, about the Tenth 

Week. X 1$. — (Author's case.) 










Fig. 105. — Amniotic Cavity Inflated, showing Maternal Surfaces of Placenta 
and Amnion and Umbilical Cord Emerging from Cavity of Amnion. , Full 
Term. — (From a photograph of a fresh specimen.) 



THE PLACENTA: THE UMBILICAL CORD. 



75 




Fig. 106. — Placenta and Unruptured Membranes at the Thirty-eighth Week 
(One-third natural size.) — (Author's collection.) 




Fig. 107. — Membranes of Fig. 106 
formaldehyde before rupturing 



Cut Open to show Fetus. Specimen hardened in 
(One-third natural size.) — (Author's collection.) 










v 






. 



Fig. 108. — Fetal Surface of Placenta 
at Term. — (Minot.) 




Fig. ho. — Connective Tissue of the Um- 
bilical Cord of a Human Embryo op 
about Three Months. X 511 diam- 
eters and reduced. Stained with alum 
cochineal and eosin. — (Minot.) 



'•lip^J? 



*¥ 




Fig. hi. — Cross-section of Umbilical 
Cord at Term. X about 12 diameters. 
Y, Remnant of the allantois; V, omphalo- 
mesaraic vein; A, A, umbilical arteries. — 
Minot.) 






- 



Fig. 109. — Section of Human Placenta 
of Seven Months in situ. Am., Amnion; 
Cho., chorion; Vi, trunk of villus; vi, sec- 
tions of villi in the substance of the 
placenta; D, decidua basalis; Mc, mus- 
cularis; D\ compact layer of decidua; 
Ve. t uterine artery opening into the pla- 
centa. The fetal blood-vessels are drawn 
black; the maternal blood-spaces are left 
white; the chorionic tissue is stippled 
except the canalized fibrin, which is 
shaded by lines; the remnants of the 
gland-cavities in D" are stippled black. — ■ 
(Minot.) 

76 




CDG; 



A 



All 



A 



Fig. 112. — Diagrammatic Section of Um- 
bilical Cord of a Human Embryo. — (W. 
His.) Am., Amnion; md., medullary 
groove; V.V., umbilical veins; A. A., um- 
bilical arteries; All., allantois ; coe, coelom. 
(Minot.) 



NUTRITION OF THE OVUM, EMBRYO, AND FETUS. 



77 



The two veins fuse early, leaving only one (Fig. 99), which comes to lie between 
the arteries, so that the funic pulse can be easily felt. The vessels are coiled from 
right to left, there being ten to twelve such turns. The spiral aspect thus given 
to the cord has been variously explained. One cause assigned is the fetal move- 
ments; another, the fact that the growth of the blood-vessels in length is more 
rapid than that of the connective tissue. The walls of both arteries and vein 
are of about equal thickness. The calibre of the vein is in excess of that of 
the arteries; and while the vein has semilunar valves, the arteries have circular 
valves. The length of the cord averages about 22 inches (50 to 60 cm.), though 
when very long it may measure 64 inches (160 cm.), while the shortest on record 
is 4.8 inches (12 cm.). Its diameter is from -f to -§- of an inch (1.1 to 1.5 cm.). 



c.s. 




Fig. 113. — Section of Injected Full-term Placenta, c.s., Cotyledon septum; a., 
amnion; c, chorion; d.s., decidua serotina; m.i.v., muscle with injected vessels. — 
{Leopold?) 

The strength of the cord varies; its tensile power at term ranging from 5 to 
12 pounds (2 to 5 kilograms). Its function is twofold: It carries nourishment 
from the mother to the fetus as well as waste matter from the fetus to the pla- 
centa. 

Nutrition and Metabolism of the Ovum, Embryo, and Fetus.* 

Ovum. — The primordial human ovum in the ovary derives the nourishment 
by which it grows from the general blood and lymph supply of the ovary, and 



* The term ovum, as here used, indicates not only the unfertilized egg, but also the 
fertilized egg and the early stages of its development ; it therefore includes not only the 
embryo but the membranes. The term fetus is used to designate somewhat loosely the 
later stages of the developing organism. 



78 PHYSIOLOGICAL PREGNANCY. 

in so doing lays up a small amount of nutriment in comparison with that of the 
germ-yolk or deutoplasm or food-yolk (Fig. 94). It is still an open question 
whether the follicle-cells surrounding the ovum contribute directly to its 
nourishment. As the ovum passes through the oviduct, as already stated, it in- 
creases in size by absorption of liquid, which separates the primitive chorion 
from the germ mass (Fig. 53). Later, and until it possesses vessels and circu- 
lation, it derives its nourishment from the intimate relations of the chorionic 
villi with the maternal blood (Fig. 45). The decidua vera, by reason of its 
increased cell-formation, indicates the presence of active metabolism favorable 
for the production of nutritive substances available for the growing embryo. 
There has been endless discussion concerning the intervillous spaces. One theory 
regards them as dilated uterine glands which secrete "uterine milk" for nourish- 
ing the ovum. It is now known that the glands become practically closed and 
that their ducts degenerate before the growing villi. 

During the third week the vitelline or earliest embryonic circulation develops, 
beginning in the mesodermic layer of the yolk-sac in the form of blood islands 
(Figs. 60 and 61). In the mean time the original sparse food-yolk has increased 
in amount within the yolk-sac, and the blood islands unite to form vessels 
which again combine to form the omphalomesenteric or vitelline veins by which 
the contents of the umbilical vesicle are carried to the embryo proper for its 
nourishment. At the same time the heart and systemic vessels arise (Figs. 
61 and 66) and blood passes through the vitelline veins into the sinus venosus. 
Then, mixing with blood returned by the systemic vessels from the body of the 
embryo, it passes into the single auricular segment or caudal end of the tubular 
heart. The blood is conveyed from the anterior or arterial extremity of the 
heart through the truncus arteriosus to the aortic arches (Fig. 71); from the 
latter it flows into the two primitive aortae. The smaller quantity is carried 
into vessels which nourish the embryo, while the greater portion reaches again 
the vascular area by the vitelline arteries. Thus a complete circulation in 
closed vessels is formed for the nourishment of the embryo. 

True Chorion. — The development of this organ has already been described. 
The villi, hollow at first, are invaded, soon after their appearance, by mesoderm 
and then by blood-vessels derived from others which grow out along the abdom- 
inal stalk. With the development of these vessels the primitive chorionic circu- 
lation is established, which rapidly supersedes the vitelline. With the distinct 
localization of the placenta this becomes the placental circulation. After the 
earlier stages of development, all the returning placental blood passes through 
the liver on its way to the heart, but when the placental circulation becomes 
more extensive the extra work is assumed by the development of the ductus 
venosus, through which a considerable amount of blood passes directly into 
the inferior vena cava without traversing the liver (Figs. 98, 99, 100, and 101). 

Functions of the Placenta. — The placental functions are varied, and it may 
be stated in general that it assumes the role of several other organs, the lung 
or gill, the alimentary tract, liver, and kidney. It aerates the fetal blood, 
supplying it with oxygen so that it is the respiratory organ of the fetus. It 
absorbs nutriment from the maternal blood, thus playing the part of the mature 
alimentary tract. It has been shown, according to Bernard, to possess a glyco- 
genic function analogous to the latter action of the liver. It also serves the 
purpose of an excretory organ, eliminating not only the carbon dioxid but other 
abundant waste products of the fetal metabolism. Interesting work has been 
done, showing the peculiar selective power possessed by the epithelial cells of 
the chorionic villi. Thev eliminate the carbon dioxid of the fetus, and if the 



NUTRITION OF THE OVUM, EMBRYO, AND FETUS. 79 

interchange of gases were reversed, the villi absorbing carbon dioxid from the 
maternal blood, this would prove fatal to the fetus. 

Fetal Blood. — In the early months of gestation the fetal blood contains 
nucleated red blood-corpuscles, sharply distinguishable from those of the mother. 
•At first these are few in number, but increase very rapidly; so that in well- 
preserved specimens the vessels are large, conspicuous objects and are crowded 
with corpuscles. At about the third month the majority of these cells have 
been replaced by non-nucleated corpuscles similar to those of the adult. The 
relative quantity of blood in the fetus and placenta undergoes considerable 
variation, the placenta at first having the larger amount; later the fetus and 
placenta contain about equal amounts, while still later the quantity in the fetus 
exceeds that in the placenta. The fetal arterial blood-pressure is about half 
that of the newly born child, while the venous pressure is much higher. The 
velocity of the blood in the umbilical arteries is far slower than in adult arteries 
of similar calibre. The fetus eliminates about the same volume of carbon 
dioxid as it absorbs of oxygen. This latter amount is about one-fourth that 
used by the maternal organism, and the amount of gas concerned in the pla- 
cental system is about one-half that which is used in the lung during respiration. 
In this way the slight metabolism of the fetus is explained; consequently when 
the communication with the mother is severed, the possibility of survival is 
longer, and is not followed by immediate suffocation, while it also accounts 
for the slight difference in temperature of mother and child. 

Kidney Excretion. — The kidneys begin to assume functional form at the 
seventh week. At first their ducts communicate with the rudimentary allan- 
tois, but since the bladder is derived from this organ, the ureters finally empty 
into that viscus. In the course of development urine is excreted by the fetus 
from time to time, as can be proved by the ^presence of urea in the amniotic 
fluid. There is always a certain amount of albumin in the fetal urine. There 
is a specially important medico-legal point in connection with the appearance 
of the kidneys: it is the formation of dark yellow infarcts, which are invariably 
present even if the infant has breathed but for a very short time before death. 
Their causation is not known. 

Bowel Excretion. — The bowels are normally inactive in intrauterine life, 
although in pathological conditions — e. g., apoplexy, coiled cord, compressed 
cord, etc. — there may be a discharge of meconium. This should be a danger- 
signal when occurring in labor, unless there is a breech presentation. 

The Fetal Circulation. — As stated in the section on nutrition, the first signs 
of the blood and blood-vessels in the embryo are the blood islands in the um- 
bilical vesicle. The heart in reptiles, birds, and mammals, so far as has been 
sufficiently determined, has been found to develop as two independent tubes 
in the visceral layer of the splanchnopleure of the neck region. As the two 
visceral layers fold over the ventral side of the embryo and fuse, the double 
heart also fuses to form a single tubular heart. The separation into auricles 
and ventricles of a right and a left heart is due to the growth of valves and par- 
titions in this single tubular heart. From the cephalic end of the primitive 
tubular heart extend two primitive aortse, and from the caudal or venous end 
extend the two vitelline veins. All of the subsequently developed arteries 
and veins are likewise in pairs except the posterior cava (inferior vena cava). 
The adult condition of the vascular system is attained by two processes: viz., 
suppression and fusion. The suppressions and fusions are shown in part in 
Figs. 68 and 69. Advancing from the primitive embryonic condition, the vessels 
of the allantois and placental circulation soon cause the development of a 



80 



PHYSIOLOGICAL PREGNANCY. 




Fig. 114. — The Fetal Circulation, ao, Aorta; a.pu, pulmonary artery; au, umbilical 
artery; da, ductus arteriosus; dv, ductus venosus; int, intestine; vci and vcs, inferior 
and superior vena cava; vh, hepatic vein; vp, vena portae; v.pu, pulmonary vein; vu, 
umbilical vein. — (From Kollmann.) 



THE FETAL CIRCULATION. 81 

more complicated system, in which the heart and liver play important roles. 
In the later months of pregnancy the blood, laden with nutriment for the 
developing fetus, collects from the ultimate venous rootlets in the chorionic villi 
and ultimately finds its way to the (i) umbilical vein. At first there are two 
umbilical veins, but soon the right fuses with the umbilical cord and only the 
left persists. This enters by way of the umbilical cord, passes first to the navel, 
and thence upward along the free suspensory ligament of the (2) liver to the 
under surface of this organ, where it subdivides into several branches. Two 
of these go to the left lobe and the others to the lobus quadratus and the lobus 
Spigelii. The vein again subdivides at the transverse fissure into two branches, 
the larger of which, joining with the portal vein, penetrates the right lobe. The 
smaller, as the (3) ductus venosus, or duct of Arantius, passes on across the 
inferior hepatic surface until it meets the (4) left hepatic vein just at that point 
where the latter vessel joins the (5) inferior vena cava. The blood which circu- 
lates through the liver undoubtedly undergoes certain changes in metabolism, 
and finally collects again in the hepatic vein, through which it flows to the 
ascending vena cava. Thus there are two avenues through which the blood, 
flowing through the umbilical vein, reaches the inferior vena cava; the greater 
part, together with the portal venous blood, circulating through the liver, pre- 
vious to entering the vena cava by the hepatic vein. The remainder goes 
directly to the vena cava by the union of the ductus venosus and the left hepatic 
vein. The blood coming from the ductus venosus and hepatic veins mingles 
in the inferior vena cava with that from the lower extremities and the abdominal 
viscera. It flows into the (6) right auricle, and, directed by the (7) Eustachian 
valve, it courses through the (8) foramen ovale into the (9) left auricle. Here 
it joins a little blood that has come from the lungs by the pulmonary veins. 
It then flows from the left auricle to the (10) left ventricle, and thence into the 
(11) aorta, by which it is in great part taken to the (12) upper extremities and 
(13) head. A little passes down by the (14) descending aorta. The blood from 
the head and upper extremities is collected by the (15) venous radicles and finally 
reaches the branches of the (16) superior vena cava, known in earlier stages of 
development as the right duct of Cuvier. This is formed by the junction of a 
superior vein (the primitive jugular) and an inferior cardinal vein, the corre- 
sponding left duct disappearing in the process of development. The superior 
vena cava empties into the (17) right auricle, where it mingles with a small 
quantity from the inferior vena cava; it then passes over the Eustachian valve 
into the (18) right ventricle, and thence into the (19) pulmonary artery. Since 
the fetal lungs are solid and almost impervious, but a small portion of the blood 
from the pulmonary arteries passes to them and is then returned by the pul- 
monary veins to the left auricle. The greater quantity flows through the (20) 
ductus arteriosus , reaching by this channel the (21) descending aorta (see 14), 
where it joins the small part of the blood from the left ventricle which has also 
passed into this artery. It now descends to supply the (22) abdominal and 
pelvic viscera and the (23) lower extremities , although its greater part flows through 
the (24) hypogastric arteries to the (25) umbilical arteries and the (26) placenta. 
Peculiarities of the Fetal Circulation. — Several facts stand out with 
special clearness in this process of fetal circulation: (1) The duplex function 
of the placenta — respiration and nutrition. In this organ the venous or impure 
blood is oxygenated and surcharged with nutriment, and returns to nourish 
the fetus. (2) By far the greater part of the blood of the umbilical vein circu- 
lates through the fetal liver, which fact accounts for the very large size of that 
organ, especially in early fetal existence. (3) The right auricle is the meeting- 



82 PHYSIOLOGICAL PREGNANCY. 

place for a dual current, that from the inferior vena cava being guided by the 
Eustachian valve into the left auricle, while the blood coming from the upper 
extremities and the head descends from the right auricle into the right ventricle. 
In early stages the entrance of the ascending vena cava is almost directly into 
the left auricle, so that there is probably little or no mingling of the two streams, 
but later the two auricles are more definitely separated and a certain mixing of 
the two currents occurs. The blood from the placenta, together with that 
from the ascending cava, is carried through the left heart almost directly to the 
aortic arch, whence it proceeds by means of the large aortic branches which 
are given off near the heart to the head and upper extremities, thus accounting 
for the extremely well-developed condition of these parts ; while the blood that 
has already circulated in the upper parts, being thereby deprived of most of 
its nutriment, is carried, together with a small part from the left ventricle, to 
the viscera and lower extremities; and this fact consequently accounts for the 
small size and poor state of development of the latter. 

Characteristic Features. — The characteristic features of the fetal cir- 
culation are (i) the ductus venosus, (2) the ductus arteriosus, (3) the foramen 
ovale, (4) the hypogastric arteries, and (5) the umbilical vein. After birth 
circulation and respiration take place as in the adult, although the changes 
leading to the complete functional development of the systems and the atrophy 
of the fetal structures take a considerable period of time. 

The Earliest Human Ovum. — The earliest ovum in an apparently normal 
condition is that described and figured by Peters in 1899. It was sectioned 
with a portion of the uterine wall in which it was partially embedded. The 
extreme limits of the ovum are about 0.12 X 0.06 X 0.06 inch (3 X 1.5 X 
1.5 mm.), in the form of a flattened sphere. The outer surface or chorion is 
covered by villi, and it is found that it is a hollow sac, the cavity of which 
measures 0.064 X 0.032 X 0.036 inch (1.6 X 0.8 X 0.9 mm.). Within the sac 
of the chorion and attached to one side is a cellular mass about 0.008 inch (0.2 
mm.) in diameter and containing two cavities. The cavity lying nearer the 
chorion is the amnion; the other cavity is the yolk or umbilical sac. The amnion 
is formed as a closed sac of a single layer of cells which are elongated on the 
side away from the chorion; i. e., in that part where from later stages it is known 
the embryo will be formed. The yolk-sac is lined by entodermal cells, and 
between it and the above-mentioned thickened ectodermal cells is a layer of 
mesoderm which not only lies between ectoderm and entoderm, but completely 
envelops the yolk-sac and the amniotic sac and forms a connection between 
these and the chorion and then forms a complete lining for the chorion. Thus 
it is seen that in this early human embryo, in which the body is represented 
by a flat or concave disc of ectoderm, a layer of mesoderm, and a sac of ento- 
derm, the relative rate of development of parts has been quite different from 
that described above for the rabbit. This difference becomes more apparent 
when the membranes are discussed. But it is seen that there is essential unity 
in the fact that the three germ -layers exist. Just how they arise in man must 
await solution until still younger human embryos are as carefully preserved and 
studied as was Peters 's specimen. 

Characteristics of the Ovum, Embryo, and Fetus in the Several Lunar Months 
of Gestation. — These are of value to enable us to determine the exact period 
of gestation, the cause of the premature interruption of pregnancy, the clew 
to many congenital deformities and intrauterine diseases and accidents, and 
tests of maturity. 

Embryos of the First Month. — The great size of the ovum described 



CHARACTERISTICS OF THE OVUM, EMBRYO, AND FETUS. S3 

by Peters is 0.12 X 0.06 X 0.06 inch (3 X 1.5 X 1.5 mm.); and of the em- 
bryonic area about 0.0076 inch (0.19 mm.). The chorion is hollow with a 
mesodermic lining and solid epithelial villi. The amniotic sac is formed and 
the embryonic area is merely a thickened portion of this sac. The yolk-sac 
is larger than that of the amnion. The embryonic mass is attached to the 
chorion by a wide mesodermic connection which completely separates the 
latter from the amniotic epithelium. Spee's specimen (Fig. 59) measures 0.28 
Xo.22inch(7 X 5.5 mm.), and the embryo 0.0148 inch (0.37 mm.). Themeso- 
dermic connection of embryonic mass with the chorion is narrower and blood 
islands have appeared on the yolk-sac. In Eternod's specimen the chorion 
measures 0.432 X 0.328 X 0.24 inch (10.8 X 8.2 X 6 mm.) and the embryo 
0.052 inch (1.3 mm.). The embryonic area is somewhat elongated and shows 
a neural groove and neurenteric canal. The heart is at the extreme cephalic 
end of the embryonic area. Vascular connections are established between 
yolk and embryo and also with the chorion. In Spee's specimen (Fig. 59), 
measuring 0.072 X 0.06 inch (1.8 X 1.5 mm.) with embryo 0.0616 inch (1.54 
mm.), the chorionic villi are already branched with mesoderm penetrating 
them. The allantoic rudiment extends into the abdominal stalk, but heart and 
blood-vessels do not seem to be so far advanced as in Eternod's smaller specimen. 
At the end of the third week (Figs. 98 and 99) the ovum measures about 
1 X 0.8 inch (25 X 20 mm.) and the embryo 0.16 to 0.2 inch (4 to 5 mm.). 
The villi are distinctly branched. The embryo is well outlined; head, trunk, 
tail, and limbs are recognizable. The neural tube is completely closed and dif- 
ferentiation into brain and eye vesicles has begun. The internal ear is a closed 
vesicle. The nasal epithelium is a thickened disc. The mouth connects with 
the pharynx, in which are four branchial clefts. The alimentary canal is a 
straight tube except for the wide connection with the yolk-sac and its ap- 
pendages; thyroid, thymus, lungs, and liver are recognizable. The heart tube 
has assumed the characteristic S-shaped twist, and though divided into auricular 
and ventricular portions, is not separated into right and left halves. The 
mesonephros (primitive kidney) is prominent. The myotomes are numerous 
and distinct. The limbs form bud-like projections. In other words, during 
the third week the majority of the organs take on recognizable features 
(Figs. 71, 72, 73, and 74). 

End of First Month or Fourth Week. — Characteristics of ovum: Waldeyer's 
classical description of an ovum four weeks old gives its size as that of a pigeon's 
egg; in length § inch by -| inch broad (20 X 16 mm.). (Mall gives 1.12 X 0.8 
inch — 28 X 20 mm. — for an embryo of twenty-seven days.) Its weight was 34.5 
grains (2.3 grams). The chorion is a flattened vesicle containing fluid and is 
made up of two walls. The inner wall is smooth while the outer one bears the 
branching villi. It is not firmly embedded in the uterine tissue and its separa- 
tion can easily take place. The yolk-sac is larger than the cephalic extremity 
of the embryo and its stalk is enclosed in the umbilical cord. A clear space 
separates the chorion from the amnion, which remains close to the embryo. 
The embryo and chorion are connected by blood-vessels which do not penetrate 
the villi (Fig. 98). 

Characteristics of the embryo: At this period the human embryo can be dis- 
tinguished from that of any other mammal only with great care. It is much 
curved, head and tail being close together, and is J inch long (7 to 8 mm.); or, 
taking the vertex-coccygeal length, f inch (20 mm.). Weight, 20 grains (1.30 
grams). The cerebral vessels are present, and the bram and spinal cord are 
enclosed. The eye and ear vesicles can both be distinguished and the nasal 



84 PHYSIOLOGICAL PREGNANCY. 

epithelium forms a slight pit. Only three branchial clefts are clearly seen. 
The tongue is a mere rudiment and the mouth is perforate. The liver shows 
marked growth and the kidneys appear about this time, with the beginnings 
of the pancreas. The heart is very prominent and its division into four cavities 
has begun. It has probably assumed its function by the third week. It is 
covered by the pericardium. The rudimentary extremities are still bud-like 
(Figs. 74 and 75). 

End of Second Month or Eighth Week. — Characteristics of ovum: The 
ovum at the end of the second month is as large as a hen's egg. It is about 
2 inches (5 cm.) long by if inches (4 cm.) wide. Its weight is from 330 to 
375 grains (22 to 25 grams). About the middle of this month there is a more 
luxuriant growth of the villi at one part on the chorion marking the origin of 
the placenta. Instead of obtaining nourishment from the umbilical vesicle, 
the fetus now depends wholly on the maternal blood for its food. The um- 
bilical vesicle is much smaller proportionally and is attached to the embryo 
by a slight pedicle. The amnion is distended with fluid but is not yet in con- 
tact with the chorion (Figs. 101 and 103). 

Characteristics of the embryo: The vertex-coccygeal length is about an inch 
(2.5 cm.), the total length being about the same. Its weight is nearly 60 grains 
(4 grams). The head is about as large as the trunk. The neck is formed. All 
the visceral clefts except the first are closed. This latter forms the external 
auditory meatus, tympanum, and Eustachian tube. The superior and inferior 
maxillary processes are formed. Bone nuclei appear in the clavicles and lower 
jaw. The salivary glands and dental groove are formed. There is decrease 
in the size of the wide oral opening. According to His, the embryo is trans- 
formed into the fetus when it has reached a length of about 0.6 to 0.64 inch 
(15 to 16 mm.); for at this stage the shape of the head and the articulation of 
the extremities are distinctly of the human type, and the tail has nearly dis- 
appeared. The hands and feet are webbed at first. The eyes, ears, and nose 
can be clearly made out. The brain vesicles, although exhibiting large cavities, 
are developing and increasing the size of the head. The body begins to straighten 
a little from the growth of the viscera. The cord is somewhat longer, and 
although the umbilical ring is contracted to some extent, there are still a few 
loops of intestine in it. The Wolffian bodies are smaller, but the kidneys and 
suprarenal bodies are developed. Although the external genitals are now 
apparent, the sex cannot be distinguished, for the elements of both sexes are 
equally present (Fig. 77). 

End of the Third Month or Twelfth Week. — Characteristics of ovum. 
The ovum is about the size of a goose-egg. It averages 4-| inches (11 cm.) in 
length. The placenta, though small, is now complete, and the chorion loses its 
villi except at this point. The amnion is in contact with the chorion. 

Characteristics of the fetus: The vertex-coccygeal length of the fetus is 3.2 
inches (7 to 8 cm.), while the total length is 4 inches (10 cm.). It weighs about 
450 grains (30 grams). The cord, as it lengthens out, begins to make spiral 
turns, while the umbilical ring narrows and the intestines are now wholly within 
the abdomen. The sex can be distinguished by the appearance or absence 
of a uterus. The scrotum and labia majora are composed of skin folds and 
the penis and clitoris are equal in length. The nails are fine membranes, and 
the webbed appearance of the fingers and toes disappears. Nearly all the 
bones present points of ossification. The neck is longer, while the ribs mark 
the line of division between the abdomen and chest. The palate is formed 
between the oral and nasal cavities. Teeth are forming and lips close the 



CHARACTERISTICS OF THE OVUM, EMBRYO, AXD FETUS. 85 

mouth. The eyes are relatively nearer together and become covered by the 
lids. The proctodeal or anal opening is perforate (Fig. 78). 

Exd of the Fourth Month or Sixteenth Week. — Characteristics of the 
fetus: The fetus is 3 inches long (7.62 cm.) from coccyx to vertex, the entire 
length being 5 inches (12.7 cm.). The weight is 1800 grains (120 grams). The 
placenta continues to grow and the cord becomes more spiral in form. The 
sex is clearly defined. Lanugo develops. There is meconium in the intestines. 
The umbilical cord is thicker on account of the beginning formation of Wharton's 
jelly (Fig. 79). 

Vitality: There may be feeble movements of the limbs, and if the child is 
born it may live some hours, endeavoring during this time to breathe. 

Exd of the Fifth Month orTwextieth Week. — Characteristics: Thevertex- 
coccygeal length is 4.5 inches (10.16 cm.), the total length 8 inches (20.32 cm.). 
The weight is 4095 grains (273 grams). The cord is about 12 inches (30 cm.) 
long. Here and there are patches of vernix caseosa. The face is wrinkled 
and has a senile appearance. The eyelids are opening. The head is huge, 
comparatively. There is more fat on the body (Fig. 132). 

Vitality: It is. as a rule, during the fifth month that the mother feels quicken- 
ing. The fetal heart sounds are audible. If born at this time, the fetus gener- 
ally dies at once, though it may live a few hours. It ma}- breathe and cry 
(Figs. 72 and 118). 

Exd of the Sixth Moxth or Twenty-fourth Week. — Characteristics: The 
fetus is 6.15 inches (15.87 cm.) long from vertex to coccyx, with a total length 
of 12.20 inches (31. 11 cm.). It weighs ii pounds (680 grams). The skin is 
richer in fat, the hair on the head grows. There are distinct brows and lashes. 
The head is large. The cord is midway between the symphysis and the xiphoid 
cartilage. The testicles approach the inguinal rings. 

Vitality: A fetus born at this time might live for fifteen days, but it would 
finally die from insufficient air- supply, for the finer air-passages are yet un- 
developed. There would also be imperfect assimilation of food and rapid loss 
of heat. 

Exd of Seventh Month or Twenty-eighth Week. — Characteristics: The 
vertex-coccygeal length is now about 8 inches (20.32 cm.), the total length 
14.4 inches (36.19 cm.), and the weight has reached 2\ pounds (1100 grams). 
The pupillary membrane disappears. There is considerable meconium in the 
large intestine. Lanugo covers the body except the palms of the hands and 
the soles of the feet. 

Vitality: A child born about this time very seldom survives. However, 
no effort should be spared to save life, for, according to Lusk, it may be owing 
to the skepticism of the physician in regard to the viability of these infants 
that so many have died. 

Exd of the Eighth Moxth or Thirty-second Week. — Characteristics: The 
vertex-coccygeal length is 10.20 inches (26.03 cm.), the entire length 15.80 
inches (40 cm.), the weight is 3^ pounds (1571 grams). The lanugo on the 
face is becoming more scanty, but the hair on the scalp is thicker. One testicle, 
generally the left, has descended into the scrotum. In the lower epiphysis of 
the femur ossification begins. The nails do not yet project beyond the finger- 
tips, although they are firmer in consistency. The cord is relatively a little 
lower in its insertion than it was the previous month. 

Vitality: With very watchful care a child born at this time may survive. 

Exd of the Ninth Month or Thirty-sixth Week. — Characteristics: The 
vertex-coccygeal length is 11.10 inches (27.94 cm.), the total length 17.25 inches 



86 PHYSIOLOGICAL PREGNANCY. 

(44 cm.), and the weight is 5^ pounds (2640 grams). There is a further 
increase in the subcutaneous fat. The development of the nails is not yet 
complete. The cranial bones are compressible and very susceptible to moulding. 
The diameters of the head are about 0.4 to 0.6 inch (1 to 1.5 cm.) less than 
those of the average fetus at full term (Fig. 107). 

Vitality: With ordinary care the fetus almost invariably survives. 

End of the Tenth Month or Fortieth Week. — Characteristics: The vertex- 
coccygeal length is 14.8 inches (37 cm.), the total length 19.84 inches (50 cm.), 
and the weight 7 pounds (3200 grams). The skin is pink, but paler, more 
abundantly supplied with fat, and has less lanugo. The nails are perfectly 
developed and project beyond the finger-tips. The eyes are opened. The 
ossification center in the lower epiphysis of the femur is 0.2 inch (5 mm.) in 
diameter, and that of the cuboid bone is just making its appearance. The 
diameters of the skull are normal (Fig. 136). (See Physiology of Labor, Part 
IV.) 

Embryo, Fetus, and Uterus in the Several Months of Gestation. — Although it 
is customary to measure embryos from vertex to sole, measurement of the trunk 
(or, in youngest embryos, the two extreme points) is doubtless more exact. 
During the first and second months only the trunk can be measured, and in the 
third and fourth months the legs cannot readily be extended. The notable dif- 
ferences of various authorities may be explained in part by the fact that em- 
bryos preserved in alcohol diminish in weight from 3 to 5 per cent, on an average 
(1 to 14 per cent, extremes) according to the strength of the fluid; and in part 
by fluctuations in the estimation of the age. Exact data upon these points 
are entirely wanting. It is best to be guided in judging the age by certain 
developmental signs, such as growth of lanugo in each month, etc. In the 
following table (pages 88 and 89) the vertex-coccygeal lengths of the embryo 
and fetus are from Schultze's figures.* The weights are those of Droysen and 
Gottengen and the size and shape of the uterus are the author's estimates. 
The last measurements, it must be remembered, are influenced by the 
presentation, size, and number of the fetus, by the size and position of the 
placenta, by the amount of liquor amnii, and by pathological conditions. 

Physiology of Sex. — The scientific interest in the subject of sex, which has 
of late years greatly increased, is a natural sequence of a many-sided study 
of the entire question. Some of these studies are of a general biological trend, 
dealing in particular with such subjects as artificial fertilization of ova; others 
refer to sex-control in breeding; others, again, to the ethnological aspect of 
sex — mutual attraction and selection of the sexes, the evolution of secondary 
sexual attributes, as female modesty, etc. Finally, even so repellant a subject 
as sexual inversion has contributed its share to the general fund of scientific 
interest. 

In view of the great and increasing importance of the subject, it is neces- 
sary to touch briefly upon such of its many aspects as have some bearing upon 
obstetrics. It is hardly necessary to insist on the practical bearing of such 
studies. A better acquaintance with the physiology of sex should often lead 
to happy and fruitful marriages in cases where corresponding ignorance would 
surely result in ill-assorted wedlock, sterility, unhappy marital state, and 
divorce. The modern study of sex is especially invaluable for the correct 
bringing-up of children, particularly daughters. Moreover, the subject has a 
special interest for the statesman and philanthropist, for in the modern move- 

* Schultze: " Grundriss der Entwicklungsgeschichte des Menschen und der Sauge- 
thiere," Leipzig, 1897, p. 137. 



EVOLUTION AND DETERMINATION OF SEX. 87 

ment toward emancipation of woman from ancient opinions is involved a 
certain degree of unsexing, and of race suicide. Something must be devised 
to meet the conditions which result from extinction of the primitive sexual 
instincts of women. 

Evolution and Determination of Sex. — Introduction. — Some of the prob- 
lems connected with the physiology of sex have a special importance for the 
human race, more particularly that of the control of the procreation of sex. 

General Summary. — The radical difference in sex can hardly be logically 
ascribed to anything less radical than a fundamental distinction which exists 
in the constitutent cells of the body. A cell exists as an individual by a syn- 
thetic, constructive faculty which enables it to assimilate nutriment from 
within and increase in size. This so-called anabolic phase of cell-life is there- 
fore distinctly vegetative in character. But it is a law that protoplasm must 
disintegrate into less complex compounds, and that the waste must be made 
good. Any manifestation of energy — of function, in other words — involves an 
analogous waste and necessity for repair. Anabolism and katabolism must 
therefore exist side by side in any cell, but one phase of metabolism may pre- 
ponderate over the other to a greater or less extent. A given cell may be 
chiefly anabolic, vegetative, and passive in the beginning of its career, and 
katabolic and active at a later period. But it seems reasonable to suppose 
that in any cell there must be an inherent tendency to the preponderance of 
one or the other aspect of metabolism; so that in the cellular units which are 
formed by segmentation of parent cells, a slight preponderance of cells with 
katabolism in the ascendant might tend to produce a variation from the parent 
type; and this variation would amount in time to the evolution of a male type 
from the primitive bisexual or feminine stock. A still more interesting phase of 
reproduction, which, however, has been regarded as degenerate sexuality rather 
than as a primitive ante-sexual manifestation, is parthenogenesis or spontaneous 
fertilization of ova. This phase of reproduction has come into prominence 
through the possibility that mature individuals may be made to develop from 
the unfertilized ova of certain species by the simple addition of certain inorganic 
chemical substances. The fact that stimuli such as corrosive sublimate may 
produce the same approximate result upon unfertilized ova as the spermato- 
zoids, gives the latter a somewhat lower status in the matter of fertilization 
and reproduction than is readily conceivable from the standpoints of the equality 
of sex. In certain cases some diseased condition furnishes the stimulus which 
leads to parthenogenesis, and, generally speaking, this phenomenon occurs under 
a number of conditions. Typical parthenogenesis occurs as high in the scale 
of animal life as the crustaceans and insects, and is not absolutely unknown 
in the plant world. The offspring of parthenogenetic ova are various, one or 
the other sex predominating. 

Determination of Sex. — Speculation on the evolution of sex appears to 
show that metabolism may play so prominent a part therein that sex might 
be controlled through nutrition. Thus, as far back as 1889, Geddes and Thom- 
son expressed themselves as follows in their work on the "Evolution of Sex": 
"Nutrition is one of the most important factors in determining sex." In 
illustration, note the experiments of Yung, which raised the percentage of 
females from 56 to 92 by good feeding; the case of bees, where the difference 
between queen and worker well illustrates the normal results of slight nutri- 
tive advantage; also the case of humble-bees with three successive broods 
increasing in nutritive prosperity and femaleness; experiments of Siebold 
with a wasp, which showed most females under favorable conditions; Aphides, 



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89 



90 PHYSIOLOGICAL PREGNANCY. 

in prosperity of summer, yield a succession of parthenogenetic females, while in 
cold and scarcity of autumn, males return; starved caterpillars of moths and 
butterflies become males. Also the facts noted by Giron, Dusing, and others 
on the influence of good nourishment of mammalian mothers in favoring female 
offspring ; the hints of the same results in the human species ; the various obser- 
vations in regard to plants which favor the same general conclusions. As to 
the influence of temperature, favorable conditions again tend to femaleness of 
offspring; extremes to males. These factors are, then: (a) nutrition (age, etc.) 
of parents ; (b) condition of sex-elements (as to nutrition) ; and (c) environment 
of embryo. 

In 1 90 1 Schenk * published a method for control of sex which was based 
wholly on the metabolic theory. He determined the character of metabolism 
of the mother by estimating the nitrogenous waste as revealed by uroscopy. 
A certain degree of proteid dissolution, by indicating a preponderance of katabol- 
ism over metabolism, was thought to favor the birth of a male. The diet 
was of a character to favor katabolic activity, i. e., the nitrogenous output 
must exceed the income. The attempt at control was exercised early in preg- 
nancy, — even before conception in some cases, — and inability to produce 
excess of nitrogenous waste by diet was held to presage the birth of a female. 

Schenk's method failed in practice, and not only his views, but their author, 
eventually fell under the disapprobation of his colleagues; so thus it is un- 
necessary to dwell further upon this epoch in our attempts at sex-control, for 
it seems to be settled that the close relationship between sex and metabolism 
cannot be utilized here. Schenk is, however, entitled to some credit for having 
made serious and systematic efforts in this direction. Quite recently the 
present state of our knowledge of this subject has been summed up by Professor 
Schultz, f of Jena. The only factor universally admitted to exist is heredity, 
preponderance of one sex over the other being recognized as a distinct family 
trait. Upon other points views diverge — save, perhaps, for the fact that all 
repudiate Schenk's metabolic theory. 

Two principal views exist: the first, held by Schultz and by Lenhossek 
(the author of a very recent monograph on sex-control), attributes sexual 
differences to the unfertilized ova themselves. From this point of view the 
male parent has nothing to do with deciding the sex of the offspring. The 
opposite view is maintained by Doderlein, who believes that the father at 
least plays some part in the determination of sex, and that the unfertilized 
ova are sexless. The latter view is in accord with the "law of Hof acker and 
Sadler," according to which the greater the age-superiority of the husband 
over the wife, the greater the likelihood of male offspring; and also with the 
"law of Starkweather," which states that the "superior" parent tends to re- 
produce its own sex (superior having reference to physical and mental traits). 

Lenhossek argues that ova have definite sex in the ovary, because unioval 
twins are always of the same sex — either male or female. This is certainly a 
biological law without known exceptions, and appears to argue strongly for 
the sex of ova. As for "laws" like that of Hofacker and Sadler, Lenhossek 
denies the validity of the statistics upon which they are based. Schultz now 
attempts to harmonize these conflicting views. He admits that unfertilized 
ova have sex — that an ovary contains "male" and "female" ova. He also 
admits the truth of Hofacker's and Sadler's law, at least as applied to the 
breeding of horses. 

* " Lehrbuch der Geschlechtsbestimming," 1903. 
t " British Gynaecological Journal," May, 1903. 



CHANGES IN THE EXTERNAL GENITALS AND VAGINA. 91 

To reconcile these apparently antagonistic truths, it is only necessary to 
suppose that the spermatozoon can still exercise a selective power in fertiliza- 
tion, while it cannot in any way determine sex. For reasons entirely unknown, 
and even unsurmised, the spermatozoon sometimes gains access to ova of 
one sex, to the exclusion of the other; or if they gain access to each kind alike, 
tend to fertilize one kind and spare the other. 

It is thus readily seen that as far as the human species is concerned, we 
have no knowledge of determination of sex, aside from the doubtful validity 
of Hofacker's and Sadler's law, and other crude generalizations derived from 
experimental breeding of animals. It is also abundantly evident that knowledge 
of this sort cannot be utilized for the control of sex in the human species. 



II. THE PHENOMENA PRODUCED IN THE MATERNAL 
ORGANISM BY PREGNANCY. 

LOCAL PHENOMENA IN THE GENITAL TRACT, ADNEXA, PELVIS, 

AND BREASTS. 

i. External Genitals. — The vulva takes part in the general hyperemia of 
the generative system, though these changes are rarely apparent until the third 
month. The labia majora and minora are both increased in size, are more 
elastic and resisting, and there is a deeper pigmentation than normal, which 
is particularly marked in the external labia. The functional activity of the 
sebaceous follicles and sweat glands of the labia is increased, and the external 
genitals are later often bathed with a glairy mucous secretion. Somewhat 
later still in pregnancy the veins and venous plexuses are much engorged, while 
distinct varicosities are not uncommon. 

2. Vagina. — The muscular and mucous walls of the vagina are thickened 
and lengthened. This hypertrophy is particularly well marked at the upper 
portion. The walls are consequently strengthened, so as better to accommodate 
the passage of the fetus at term. The mucous membrane becomes darkened 
by pigmentation. The attachment of the mucous coat to the tissues beneath 
becomes loosened, so that its displacement is easy, and it is not infrequently 
torn off in labor, thus originating vaginal prolapse. The rugas are distinctly 
defined; the lymphatics, as well as the blood-vessels, are unusually developed; 
the tissues become softened and infiltrated, and the submucous fat decreases. 
On account of the increased quantity of blood in the loose tissues, as well as 
the venous stagnation which occurs, the vaginal surface looks violet, blue, or 
purple, instead of red as normally (Fig. 7). The mucous glands produce 
an abundant secretion, the papillae of the vagina hypertrophy, and it is not 
uncommon about the seventh or eighth month to find the surface covered 
throughout its whole extent with myriads of these little pinhead prominences, 
which have given rise to the term " granular vaginitis of the pregnant woman." 
The temperature of the vagina is slightly increased, and the augmented supply 
of blood to the part causes a distinct throbbing of the vaginal arteries, readily 
detected by the examining finger, the so-called "vaginal pulse." The apparent 
length of the vaginal canal varies according to the period of pregnancy at which 
the examination takes place. In the early weeks, before the uterus rises above 



92 



PHYSIOLOGICAL PREGNANCY. 



the pelvic brim, the vagina is shortened; afterward it increases in length till 
the middle of the eighth month (as a result of the sinking of the uterus at this 
time), when it again becomes shortened. 



MESO-SIGMOID 
UTERUS 



RECTO-VAGINAL POUCH 
RECTUM 



LEFT COMMON ILIAC V 

RIGHT COMMON ILIAC A 

ROUND LIGAMENT OF UTERUS 




DEEP EPIGASTRIC A 
ALLOPIAN TUBE 
VARY 

RO-VESICAL POUCH 
DER 



SAPHE OF LEVATOR ANI M 

EXTERNAL SPHINCTER ANI M 



i LORSAL VEIN OF CLITORIS 

VESICAL PLEXUS OF VEINS 
URETHRA 



INTERNAL SPHINCTER ANI M 

PERINEAL BODY 



Fig^ 115. — Sagittal Section 1- of Normal Adult Pelvis. — (Deaver.) 



3. Cervix. — (1) Consistency: The tissue of the non-gravid uterus is firm, 
hard, and non-elastic. With the occurrence of conception, softening begins 
at the external os, and gradually extends upward till the whole cervix is in- 
volved. It is caused by serous infiltration, with which passive dilatation of 



CHANGES IN THE CERVIX. 



93 



the blood-vessels is associated. At the end of the fourth month the lips of the 
os are entirely changed in consistence, being soft and velvety on palpation. 
By the sixth month one-half of the cervix has participated in this change, and 
by the eighth the entire cervix is involved. 

2. Volume. — The cervix takes part in the hypertrophy of the entire uterus, 
its volume changing somewhat as pregnancy advances. This increase, how- 
ever, does, not compare in extent with that of the body of the uterus. 

3. Situation and Direction. — In the first three months the cervix is 
lower in the pelvis and a trifle to the left. This position results from the in- 



URETER (BEHINO PERITONEUM) 
LOOP OF 8MALL INTESTINE 



VERMIFORM APPENDIX 

CECUM (displaced upward) 



FUNDUS OF UTERUS 

FIMBRIATED EXTREMITY OF FALLOPIAN TUBE 

SIGMOID FLEXURE (DISPLACED UPWARD) 



LOOP OF SMALL INTESTINE 




DEEP EPIGASTRIC A 
OBLITERATED HYPOGASTRIC A 
EXTERNAL ILIAC A(BEHIND PERITONEUM) 

APPENDICULO-OVARIAN LIGAMEN1 



ROUND LIGAMENT 



BLADDER (DISTENDED) 
FALLOPIAN TUBES 



URACHUS 



Fig. 116. — Pelvic Contents seen from Above. — (Deaver.) 



creased weight and the pressure upon the fundus toward the right by the dis- 
tended rectum. After the third month the cervix rises higher in the pelvis 
till the last two or three weeks of gestation, when it sinks again. Sometimes 
toward the end of pregnancy, if the head is the presenting part, it pushes forward 
the lower anterior wall of the uterus, causing the cervix to point backward, 
or even a little upward.* The cervix changes in direction according to the 
movements of the uterine body. 

4. Cervical Canal. — Coincident with the cervical softening, the cavity 
* Sacciform dilatation of the lower uterine segment. 



94 



PHYSIOLOGICAL PREGNANCY. 



becomes broader, and the external os patulous. The time of this change varies 
according as the patient is a primigravida or a multigravida. Sometimes, in 
the former case, the external os remains closed till the end of pregnancy; but 
even under these circumstances it generally becomes patulous after the seventh 
month. In multigravidae this change is more pronounced, so that in the last 
months of gestation it is often possible to feel the membranes through the 



C.l.V. s 



u.a. i.s.a. i.e. a. m s a. civ. s.f. 



i.s.p. 




u.s.l. 



i.ur.a. 



v.p.c 



Fig. 117. — The Pelvic Inlet and Female Pelvic Organs in a Woman Forty Years 
Old, Who has borne Children. The bladder is partially filled with urine. (\ natural 
size.) i.s.a., Internal spermatic artery; s.u.a., superior ureteric artery; c.i.v., common 
iliac vein; i.s.p., internal spermatic plexus; h.a., hypogastric artery; u., ureter; u.s.l. , 
utero-sacral ligament; o., o., ovary; e.i.a., external iliac artery; e.i.v., external iliac vein ; 
r.l., round ligament; e.a., epigastric artery; f.t., Fallopian tube; v.p.c, vaginal portion 
of cervix; i.e., inferior cava; a., aorta; m.s.a., median sacral artery; c.i.v., common 
iliac vein; s.f., sigmoid flexure; u., ureter; u.s.l., utero-sacral ligament; u.a., uterine 
artery; o.L, ovarian ligament; ut., uterus; b., bladder; i.ur.a., inferior ureteric 
artery. — (Tandler and Halban.) 



patulous os. The alleged shortening of the cervix, as taught by old authorities, 
has been shown to be non-existent; but during the two weeks just preceding 
labor some shortening does begin to take place, proceeding from above down- 
ward till the cervical canal is merged into the uterine cavity; this shortening 
is owing to the incipient contractions of the uterus which are preparing the 
cervix for labor. 

4. Uterus. — The most important changes in the whole organism during 



CHANGES IN THE CERVICAL CANAL. 



95 



pregnancy take place in the uterus. The alterations which the latter undergoes 
as the result of each menstrual period must be regarded as an introduction 
to that series of changes which end only with the return of the organ to its 



Fallopian 
tube 




Round 
Ligament Cyt 



Body of Uterus 
Isthmus 



Extra Vaginal 
, portwn of ^Cervix 

External os 

Posterior Wall of 
Vagina. 



Fig. 118. — The Anterior Surfaces of the Nulliparous and Multiparous Uterus 

Compared. 





"" Fundus 
FallopianTube 

Cavity of Body 



Body 

Isthmus ~~~ 
Internal os 
Cervical Canal 

Aleck 



lateral Vaaina7 

Cttl-deSnc. 
External os 



lateralJfcginalWall 
PosteriorVaginalHull 



Fig. no. — Sagittal Sections of the Nulliparous and Multiparous Uterus. 




normal condition after the expulsion of the product of conception (see Men- 
struation, page 20). 

1. Volume and Size. — The volume or size of the small, inflexible virgin 



96 



PHYSIOLOGICAL PREGNANCY. 



uterus is expressed by 2 J inches (7 cm.) in length, if inches (4.5 cm.) in breadth, 
and 1 inch (2.5 cm.) in thickness. The hypertrophy of the uterus is concerned 




\ ^ 




Fig. 120. — Virgin Cervix and Os with 
Oval Opening. 



Fig. 121. — Virgin Cervix and Os with 
Transverse Fissure. 




Fig. 122. — Virgin Cervix and Os with Oval Opening. 




Fig. 123. — Multiparous Cervix with 
Gaping Fissured Os. 







Fig. 124. — Cervix and Os of Ad- 
vanced Age with Small Round 
Opening. 



not only with the muscle-fibers, but with the connective tissue and all the 
vessels. These changes are reflex in character, and begin with impregnation. 



SIZE AND SHAPE OF THE UTERUS. 



97 



Indeed, the uterus increases up to the fourth month, even in tubal or any form 
of extrauterine pregnancy. The growth of the ovum may act at first as a 




Fig. 125. — Sagittal Section of Uterus and Pelvic Contents at the Second Month 
of Pregnancy. Retroversion. (£ natural size.) — (Schaeffer.) 




Fig. 126. — Sagittal Section of Uterus and Pelvic Contents at the Third Month 
of Pregnancy. Unusual vertical position of the gravid uterus. (£ natural size.) — 
(Schaeffer.) 

7 



■•> X 




/ 



I/ifcma/ os. 

Extmwlos 



Fig. 127. — Frozen Section of a Uterus at the Third Month. Uterus resting normally 
on the bladder. Placenta and membranes in the uterus. — (Freund.) 




Fig. 128. — Sagittal Section of Uterus 
and Pelvic Contents at the Fourth 
Month of Pregnancy. Primigravida. 
Breech presentation. Normal position of 
the uterus. (J natural size.) — (Schaeffer.) 




Fig. 129. — Frozen' Section of a Uterus 
at the Fourth Month of Pregnancy. 
Placenta and membranes are retained. 

— (Freund.) 



98 




Fig. 130. — Pregnant Uterus at the Fifth Month, showing Anterior Surface and 
Prominent Right Horn (Unicornate Uterus). — (Author's case.) 




Fig. 131. — Uterus of Fig. 130 Opened Posteriorly, showing Unruptured Amnion 
with Contained Fetus, Thickness of the Uterine Walls, and Length of Uterine 
Canal. — (Author's case.) 

99 



I. of 



100 



PHYSIOLOGICAL PREGNANCY. 







Fig. 132. — Amnion and Fetus from Fig. 131 after Entire Specimen was Hardened 
in Formaldehyde. Shows posture of fetus and shape of the fetal ovoid. — (Author's 
case.) 



Crest 




Ilium 



Tat- 



Internal os. ^£35 

IfrginaJ ? forma ?'■- 
Eocterrud os. 

Fig. 133. — Frozen Transverse Section of a Uterus from a Multigravida at the 
Thirty-sixth Week. No uterine contractions have occurred. The cervix is 
closed and the canal unshortened. Death from eclampsia. (\ natural size.) — (Leopold.) 




Internal os 



External os. 



Fig. 134. — Frozen Section of a Uterus at the Seventh Month, with Retained 
Placenta and Membranes.— (Freund.) 



101 



102 



PHYSIOLOGICAL PREGNANCY 



physiological cause of these changes, but not as a mechanical one. Uterine 
enlargement is not directly dependent upon the presence of the ovum, for the 
latter does not entirely fill the cavity of the organ at the end of the fifth month ; 
consequently it is not until this time that mechanical distention can be reckoned 
as an influential factor. At first this hypertrophic process affects all parts 
of the organ alike, but later the cervix grows more slowly than do the fundus 
and the body. At one period the walls attain the thickness of five-eighths of an 




Fig. 135. — Pregnant Uterus at Thirty-eighth Week seen from the Front. Ante- 
rior walls are held back to show the maternal surface of the placenta, the unruptured 
amnion, thickness of the uterine walls, and the length of the cervical canal. — (Author's 
case.) 



inch (1.5 cm.). The thickness, however, decreases in the latter part of gesta- 
tion, on account of extreme distention, to three-sixteenths of an inch (0.5 
cm.). The capacity of the virgin uterus, which is almost imaginary, may be 
increased as much as 519-fold at term (Krause, Levret). The outer surface 
of the virgin uterus measures six square inches, while at term it amounts to 
339 square inches. The unimpregnated uterus weighs about ij ounces (35.43 
gm.), while the pregnant organ at term weighs about two pounds (900 gm.). 



SIZE AND SHAPE OF THE UTERUS. 



103 



For the size of the uterus at the end of each calendar month see table, pages 
88 and 89. 

2. Shape. — The virgin uterus is pyriform or pear-shaped, flattened from 
before backward (Fig. 118). Its upper end or fundus, the broad extremity of 
the organ, is directed upward and forward (Fig. 117). Its lower end, or apex, 
looks downward and backward. Consequently it forms an angle with the 
vagina. During the first six or eight weeks of gestation the organ loses its 
flattened pear shape and bulges out over the cervix, in all the transverse diam- 




Fig. 136. — Frozen Section of Uterus from a Primipara at the Fortieth Week. 
Uterine contractions have just commenced. Death from eclampsia. Note the un- 
shortened cervical canal and the lateral flexion of the body and head of the fetus. 
(^ natural size.) — (Leopold.) 



eters, but more particularly antero-posteriorly ; so that now the uterus resembles 
very much an old-fashioned jug inverted (Fig. 171). Later it expands more 
in the lower segment, and by the fifth month its form is midway between spherical 
and pyriform, the vertical diameter being longest (Fig. 130). Its antero- 
posterior measurement is greatest just below the middle of the body. During 
the last of pregnancy it becomes egg-shaped, ovoid, or cylindrical (Fig. 135). 
These changes in shape occur in the normal uterus, but may be influenced by 
multiple pregnancies, by anomalies of the liquor amnii, and by pathological 



104 



PHYSIOLOGICAL PREGNANCY. 



conditions. Asymmetry of the corpus uteri often exists even at a very early 
period of pregnancy (Figs. 130, 137 to 141). Fig. 130 of the author's collection 
shows this condition. The bulging portion is often marked off from the rest 
of the corpus by a furrow (Fig. 165) (compare Diagnosis of Pregnancy). 

The shape of the uterus at the end of each calendar month is as follows: 
End of first month, pyriform, by reason of marked antero-posterior growth, 
changing to cylindrical; second month, exaggeration of first month, spherical 
form suggested; third month, almost spherical; fourth month, marked ovoid 




V 





Fig. 137. — Egg-shaped Fig. 138. — Cylindrical- Fig. 139. — Unicornate-shaped 
Uterus. shaped Uterus. Uterus. 



f' Jr 





FlG. 140. — -BlCORNATE-SHAPED UTERUS, 

Uterus Arcuatus. 



Fig. 141. — Oblique Cylindrical-shaped 
Uterus in Shoulder Presentation. 



with round anterior and flattened posterior surfaces; fifth month, exaggeration 
of fourth month; sixth month, ovoid changing to egg-shape with posterior wall 
flattened by spinal column; seventh month, egg-shaped, broadest just below 
fundus; eighth month, exaggeration of seventh month, lower portion widening 
out; ninth month or- full term, ovoid shape with predominance of longitudinal 
axis; anterior surface more convex, with marked bulging of anterior part of 
lower uterine segment, caused by fetal head. A posterior depression caused 
by the lumbo-sacral angle and fundus may be due to irregular posture of the 
fetus. 



POSITION AND AXIS OF THE UTERUS. 



105 



3. Situation or Position. — On account of increased weight, the uterus, 
in the early months of pregnancy, sinks down into the pelvic cavity. After 
the third month it rises gradually, till it almost touches the diaphragm, and 
before term it sinks again by reason of the engagement of the lower part of the 
uterus in the pelvic cavity, and the relaxation of soft parts preceding delivery. 
This is called the "lightening'' before labor. The virgin uterus is normally 
anteflexed (Fig. 115). This condition becomes much accentuated in pregnancy, 
especially when the abdominal walls are lax, as after the patient has borne a 
number of children, when anteflexion is much exaggerated. Not only does 
the sinking of the organ depend 

upon its increase in weight, but 
also on the greater surface of the 
fundus exposed to the downward 
pressure of the intestines. Before 
the pregnant uterus has risen out 
of the pelvis, the abdomen is not 
increased in size. In fact, it is 
often said to be flatter, on ac- 
count of the partial descent of 
the uterus into the pelvis. About 
the middle of the third or begin- 
ning of the fourth month, how- 
ever, the fundus slowly rises 
above the pelvic brim, and it 
may then be felt as a smooth, 
rounded tumor. 

4. Axis. — While the uterus is 
in the pelvic cavity its longi- 
tudinal axis changes from time 
to time, like that of the non- 
pregnant organ. These altera- 
tions in direction probably depend 
on the condition of the bladder. 
Later on in pregnancy, when the 
uterus has extended up into the 
abdomen, it tends to tilt forward 
against the abdominal wall, and 
its axis corresponds more nearly 
with that of the pelvic brim, the 
angle formed with the horizon 
being 30 degrees. At term, the 
position and relations of the 
uterus vary with the posture of 

the woman. While upright , the heavy fundus inclines forward against the abdom- 
inal parietes, as far as the consistency of the latter will permit. In the recum- 
bent position, the uterus rests against the spinal column in the lumbar region 
while the fundus approaches the diaphragm, and the intestines are massed 
around the organ in front and at the sides, particularly the left side (Fig. 162). 
In either lateral position the uterus naturally inclines to the corresponding 
side. In women with very lax abdominal parietes the fundus may even hang 
downward, there not being sufficient support from the flaccid muscles of the 
abdomen (Fig. 153). Besides the anterior obliquity, there is also a right lateral 




Fig. 142. — Height of 
tion of the cervix 
of Gestation. 



the Fundus and Posi- 
in the Several Weeks 



106 



PHYSIOLOGICAL PREGNANCY. 



obliquity, to explain which many theories have been advanced (Fig. 162). 
Rotation (torsion) on its longitudinal axis is often noticed, so that the ovaries 
are displaced, the left generally lying toward the middle line and forward, while 
the right is directed backward (Fig. 162). The cervix naturally follows in 
the wake of the larger body. In extreme anteflexion it cannot always be felt. 

5. Consistency. — The consistency of the pregnant uterus changes from 
the rigid, firm, inelastic condition of the non-pregnant organ to the soft, elastic 
consistency which increases with the advance of pregnancy An obscure sense 



9* 



O: ' 




I2 TN WEEK 



16™ WEEK 



J 



24™WEEK 



Fig- H3- 



Fig. 144. 



Fig. 145- 



Fig. 146. 



Figs. 143-146. — Shape of the Abdomen in a Primigravida. — {Redrawn from Hirst's 

photographs.) 



of fluctuation is often perceived. This consistency differs from that of metritis, 
which causes a hard and non-elastic uterus; from that of subinvolution, which 
gives a soft but inelastic consistency to the organ; and from that of fibroid, 
which is also hard and inelastic. So, at term, the full-grown fetus is con- 
tained within a flexible-walled cavity. 

6. Mucous Membrane. — (See Decidua, page 47.) 

7. Muscular Layers. — In the non-pregnant uterus the muscle-fibers have 
a very irregular distribution. Roebger has done very important work on this 



MUSCULAR TISSUE OF THE UTERUS. 



107 



subject, and says that we do not find definite layers of muscles. Much dis- 
cussion has taken place as to the musculature of the pregnant uterus. Luschka 
and Henle's work is as good as any. They believe the pregnant uterus to con- 
sist of three layers: (i) An external or hood-like, longitudinal layer, passing 
over from the fundus of the uterus and continuing into the ligaments (Fig. 154). 
(2) A median layer, where the network of fibers attains its greatest thickness 
(Fig. 155). (3) An internal layer, which forms the sphincters about the uterine 
orifices — tubes and os uteri (Fig. 156). These chief layers are connected by 




Fig. 14S. 



Fig. 149. 



Fig. 150. 



Fig. 147. 

Figs. 147-150. Shape^of_jthe Abdomen in a Primigravida. — (Redrawn from Hirst's 

photographs.) 



communicating groups, so that when they are separated the intervening spaces 
are rhomboidal in shape. The connective tissue between the muscle-fibers 
soon becomes increased, and toward the last of pregnancy exhibits distinct 
fibrillar (Ruge, Hofmeier). By hypertrophy and hyperplasia the three muscular 
layers are defined. The hypertrophy of the single muscle-fibers is perhaps 
the most striking change in the whole organism, the increase being eleven times 
in length and five times in width. The new muscular elements rapidly grow 
as well 




Fig. 



151. — Shape of the Abdomen in a Young Primigravida at Full Term after 
the Falling of the Uterus and in the Dorsal Posture. 




Fig. 152. — Shape of the Abdomen in a Young Primigravida at Full Term after 
the Falling of the Uterus and in the Standing Posture. 

108 



ARTERIES AND VEINS OF THE UTERUS. 



109 



8. Fibrous Tissue. — The fibrous tissue is increased, chiefly by absorption 
of fluid and consequent increase in bulk, and it sends in its newly developed 
fibers between the muscle bundles, thus adding its influence to the other factors 
which change the consistency of the uterus in the gravid state. 

9. Arteries and Veins. — The arteries increase in calibre and length. Their 
tortuosity is not lost. The veins enlarge into wide channels, the sinus uteri. 




Fig. 153. — Shape of the Abdomen in a Multigravida with a Moderate Generally 
Contracted Pelvis at the Thirty-eighth Week and in the Standing Posture. 



These penetrate between the muscle bundles and are especially well developed 
at the placental site. The walls of these channels do not collapse when injured, 
on account of the close connection between them and the surrounding connective 
tissue. They are obliterated after labor by the contraction of the uterine 
muscle, which surrounds them. These blood-vessels penetrate the minutest 
divisions of the chorion frondosum, and consist of the end ramifications of the 



110 



PHYSIOLOGICAL PREGNANCY. 



umbilical arteries and veins. The arteries and veins pursue their course side 
by side, a distinguishing characteristic of the latter being their thin walls and 
large calibre. Only capillaries occupy the terminal villi. They are, as a rule, 





Fig. 154.— External Muscular Layer of 
the Pregnant Uterus. Anterior Sur- 
face. 1, Fallopian tube. 2, Round liga- 
ment. 3, Ovarian ligament. 4, Trans- 
verse fibers. 5, Longitudinal fibers. 6, 
Z-shaped arrangement of fibers. 7, Orifice 



of external os. — (Henle.) 



Fig. 156. — Internal Muscular Layer 
of the Pregnant Uterus after 
Removal of the Two Outer Layers. 
1, Section of the external layer. 2, 
Section of the middle layer. 3, Fal- 
lopian tubes. 4, Circular fibers of 
the horns. 5, Circular fibers of the 
isthmus. 6. Circular fibers of the 
cervix. 7, Orifice of the external os. 
— (Henle.) 






just under the epithelium, and are connected by free anastomoses. They are 
so abundant that this area gives the appearance of a saturated sponge Their 




Fig. 155. — Middle Muscular Layer of the Pregnant Uterus, i, Left tube. 2, Right 
tube. 3, Fundus uteri. 4, Superficial muscular layer incised and turned back. 5, 
Flexiform fasciculas of the middle layer. 6, Elliptical openings occupied by the uterine 
sinuses . — (Henle.) 



diameter is large enough to accommodate five or six red corpuscles side by side. 
They have a delicate endothelial wall, which, together with the chorionic epi- 
thelium, alone separates the fetal from the maternal blood in the intervillous 



ARTERIES AND VEINS OF THE UTERUS. Ill 

spaces. The uterine artery is much enlarged during pregnancy, but relatively 
less so than the ovarian. As pregnancy advances it becomes more tortuous, 
its course being less direct, and its attachment to the uterine wall loosened.* 
Its level in the pelvis will depend on the upward growth of the uterus, as well 
as on its attachment to the pelvic wall, and its relation to the outer border of the 
broad ligament is lost in the latter part of pregnancy. Its relation to the ureter 
is the same in pregnant and non-pregnant uteri (Fig. 158). The ovarian artery 
is greatly enlarged in pregnancy. Its course from the point where it reaches 
the pelvic brim at the bifurcation of the common iliac artery is upward and 




,. Is. and i.g. 

}spe.p. 







Fig. 157. — Nerve-Supply of the Female Genital Organs, p.n., Phrenic nerve; s.n., 
splanchnic nerve; l.g.s., lumbar ganglion of the sympathetic; g.u.p., great uterine 
plexus; r. p. h., right hypogastric plexus; 5. p., sacral plexus; r. e.g., right cervical gan- 
glion; v.ii.. vagus nerve; s.n., splanchnic nerve; s.g., solar ganglion; s.r.g., suprarenal 
ganglion; i.r.g., infrarenal ganglion; 5. and i.g., superior and inferior genital ganglia; 
spe.p., spermatic plexus (ovarian nerves). — (Frankenhduser.) 

forward, accompanying the infundibulo-pelvic ligament, lying close to the 
ovary, overshadowing the Fallopian tubes, and finally reaching the cornu of 
the uterus (Polk) (Figs. 159 and 160). 

10. Nerves. — Many theories have been suggested concerning the changes 
in the nerves in pregnancy. Some authors believe that they are subject to no 
change whatever; others, that they grow with the other structures of the uterus. 
The increase of neurilemma only has been thought by some to account for the 
apparent increase in the fibers. Again, they have been described as increasing 
in length but not in thickness. Until this question is decided, the logical view 
* Tandler und Halban: " Topographie d. weibl. Uterus," 1901. 



112 



PHYSIOLOGICAL PREGNANCY. 



seems to be that these organs of sensation participate in the general increase 
of the other parts of the uterus. 

ii. Lymphatics. — The lymphatics increase greatly, both by hypertrophy 
and hyperplasia. The lymph spaces just below the mucous membrane are 
much increased in size, and the lymph channels which run from them through 
the muscles of the uterus reach the size of a goose-quill. Underneath the peri- 
toneum these lymph vessels form a plexus continuous with the general lymphatic 
system. On this arrangement of these absorbent vessels depends that striking 
characteristic of the uterus after labor, its readiness to take up and assimilate 




c.u 



Fig. 158. — Relations of the Ureters, Uterine Arteries, and Cervix in the Non- 
pregnant State, u., u., Ureter; h. a., hypogastric artery; s.L, suspensory ligament; 
e.i.a., external iliac artery; u.a., uterine artery; p.b.w., posterior bladder wall; r., retro- 
uterine fold; c, cervical canal; u.a., uterine artery; c.t., cellular tissue; ut., uterus. 
— (Tandler and H alb an.) 



infecting material, peritonitis frequently presenting the first symptom of thifc 
process. 

12. Peritoneum. — The connective tissue found in the uterus between its 
peritoneal covering and the muscular walls becomes less dense and more cellular, 
so that while the peritoneum in the non-gravid state was closely bound to the 
organ, allowing very little if any motion between the two, in the pregnant 
condition, especially at term, it is freely movable on the muscular coat, thus 
diminishing the risk of laceration during labor. The peritoneum at the end 
of pregnancy, before the sinking of the uterus, shows a shallowing of the anterior 



LYMPH A TICS— PERIT ONE UM. 



113 



fossa, and the pouch of Douglas is almost obliterated. The retro-ovarian 
shelves are now on a level with the pelvic brim, instead of on a level with a line 
dnvwn from the middle of the symphysis to the third or fourth piece of the sacrum. 



c.i.a. 



c.i.v 




u.l.l. 



p.c.l. 



Fig. 159. — Topography of the Uterine Artery and Ureters in Pregnancy at Thirty- 
sixth Week, p., Placenta; c.i.a., common iliac artery; c.i.v., common iliac vein; 
u., ureter; d.p., Douglas' pouch; v.f., vaginal fornix; p.c.l., posterior cervical lip; i.o., in- 
ternal os; e.o., external os; r., rectum; a. I., anterior lip; v., vagina; i.v., internal iliac 
vein; u.l.l., umbilical lateral ligament: u.a., uterine artery; b., bladder; ur., urethra. — 
(Tandler and Halban.) 



The pouch of Douglas is raised. There is backward displacement of the broad 
ligaments, from the growth of the uterus, causing the almost complete oblitera- 
tion of the posterior fossa, (a) Broad ligaments: During pregnancy the broad 
ligaments are drawn upward, so that at full term the bases of the ligaments lie 



114 



PHYSIOLOGICAL PREGNANCY. 



on a level with the pelvic brim, and extend from the pectineal eminence ante- 
riorly, to the synchondrosis posteriorly, these limits being determined by the 
round ligaments anteriorly and the ovarian artery posteriorly. Separation of the 
laminae of the broad ligaments during pregnancy causes the triangular form at 
full term, the base of the triangle corresponding to the pectineal line, and its 
apex to the horn of the uterus (Fig. 161). After delivery the ligaments slowly 
regain their position in the pelvis. Hence the ureters have no fixed relation 




l.s.u 



Fig. 160. — Topography of the Uterine Artery and Ureters in Pregnancy at the 
Thirty-sixth Week. — Same as Fig. 159 with upper portion of left uterine wall and 
a portion of the peritoneum removed, d.p., Douglas' pouch; l.s.u., lower segment of 
uterus; v.f., vaginal fornix; c.c, cervical canal; v., vagina; h.a., hypogastric artery; ur., 
ureter; i.s.a., internal spermatic artery; i.s.p., internal spermatic plexus; e.i.a., exter- 
nal iliac artery; u.a., uterine artery; e.i.v., external iliac vein; u.l.l., umbilical lateral 
ligament; v.b.a., vesical branch of uterine artery; b., bladder; u., urethra. — (Tandler 
and Halban.) 



to the broad ligaments in the latter part of pregnancy, because the ureters do 
not undergo the same displacement during gestation. (6) The utero-sacral 
ligaments are attached, in the latter part of pregnancy, to the first, instead of 
to the third or fourth, sacral vertebra, (c) The round ligaments by the growth 
of the uterus are drawn up above the pelvic outlet. 

13. Properties. — (a) Sensibility: The sensibility of the uterus undergoes 
very little change. The cervix in the non-pregnant state may sometimes even 
be cauterized without much discomfort to the patient. But the sensibility varies 



WALLS AND RELATIONS OF UTERUS. 



115 



in accordance with its cause; e. g., forced dilatation of the cervix is quite painful. 
The body, although somewhat less sensitive than the cervix, is not entirely insen- 
sible, for pain is caused by the contractions of labor, or by the introduction of a 
sound or hand. Even fetal movements are painful to some women. (b) Irrita- 
bility: This property also differs in various subjects. Irritability of the uterus, 
when excessive, is probably of pathological origin. The slightest cause in some 
women — a misstep, for example — may cause abortion; while others may ride to 
hounds with no injurious results, (c) Contractility: The muscle-fibers exhibit 
contractility, which consists in a shortening of the fibers followed by relaxation. 
Contractions occur throughout pregnancy, and are usually painless ; they promote 
the uterine circulation and help to fix the position of the child. 

14. Thickness of the 
Walls. — The great increase 
in the size of the uterine 
cavity is not due to the me- 
chanical pressure of the grow- 
ing ovum, but to the hyper- 
trophy of the walls themselves. 
If the former cause obtained, 
the pregnant uterine walls 
would be much thinner than 
those in the non-gravid state. 
In the first three months the 
walls increase a little in thick- 
ness, owing to the rapid devel- 
opment of the muscular and 
vascular systems; at the fifth 
month they are about normal 
in thickness (Fig. 131), and at 
term they are of a thickness 
about equal to that of the non- 
pregnant parietes, although a 
trifle thicker at the placental 
site; and much thinner in the 
lower uterine segment, the 
thickness thus varying at dif- 
ferent points (Fig. 135). 

15. Topographical Relations at Term (Fig. 162). — The topograph- 
ical relations of the intestines are worthy of note. They are always above, 
behind, and at the sides of the uterus, thus giving no resonance over the 
anterior abdominal wall. In front of the uterus are the vagina, the pos- 
terior surface of the bladder, and the internal surface of the anterior abdominal 
wall. Now and then, as an exception to the statement previously made, one or 
more coils of intestine intervene between the uterus and the abdominal wall. 
Behind, the uterus is in relation with the rectum, the sacro- vertebral articula- 
tion, the vertebral column, the mesentery, and a mass of intestines ; on the right, 
with the corresponding side of the pelvic excavation, the iliac vessels, the psoas 
muscle, caecum, and right abdominal wall; on the left, with the corresponding 
part of the pelvis, the iliac vessels, the aorta, the sigmoid flexure, the psoas 
muscle, and a mass of intestines which separate the uterus from the left lateral 
abdominal wall. The fundus is in relation with the transverse colon, a part of 
the stomach, the anterior margin of the liver, the ensiform cartilage for a time, 




Fig. 161. — Broad Ligaments of the Pregnant 
State. Pregnant uterus at the thirty-sixth week. 
—(Polk.) 



116 



PHYSIOLOGICAL PREGNANCY. 



and the lower floating ribs. The ovaries and Fallopian tubes are close to the 
sides of the uterus, at- a point corresponding to the junction of the upper and 
middle segments. When pregnancy is drawing to a close, a large part of the 




Fig. 



i 6 2. —Topography of the Uterus at the Fortieth Week. Right lateral obliquity 
and axial torsion from left to right of the uterus are present. — (From nature.) 



anterior uterine surface is in contact with the abdominal wall, while its lower 
surface rests against the posterior part of the symphysis pubis. The posterior 
surface leans against the spinal column; the large intestines cover the fundus, 
while the small intestines are forced to both sides. 



BLADDER, URETERS, RECTUM, BREASTS. 117 

5. Bladder. — In early pregnancy the bladder is not so capable of expanding 
in an antero-posterior direction, and so the distention takes place laterally. 
In the displacements of the uterus, which are so frequently seen in preg- 
nancy, the bladder follows the uterus. As the uterus ascends in its growth, 
therefore, the urethra elongates, and in certain uterine displacements may 
become partly or completely occluded, thus leading to overdistention of the 
bladder, paralysis of its musculature, decomposition of the retained urine, and 
cystitis. If the uterine displacement is not corrected, there may result dis- 
astrous vesical troubles, the lining membrane may be cast off in shreds, or a 
cast may be thrown off; even the muscle-layer may contribute to the general 
disturbance. As the bladder accompanies the uterus in its upward growth, 
the orifice or bulb of the urethra is elevated and hidden behind the symphysis 
pubis, and it is consequently more difficult to introduce a catheter. The canal 
also becomes more curved, so that a curved male catheter is used with more 
facility than the straight female instrument. The dragging upon the bladder 
by the initial prolapse of the uterus, together with the subsequent (third month) 
pressure of the latter when anteverted, diminish the size of the bladder, causing 
frequency of micturition. At times, when the bladder is full, a simple sneeze 
or cough will cause involuntary discharge of urine. Vesical tenesmus may 
also annoy the patient, particularly during the first three months, before the 
uterus rises; and also during the last fortnight of pregnancy, after it has fallen. 

6. Ureters. — In the latter part of pregnancy the ureters do not, as in the 
non-pregnant state, follow the pelvic wall to the ischial spines; but, having 
crossed the brim near the bifurcation of the common iliac artery, they accom- 
pany the internal iliac artery. They leave the pelvic wall about on a level with 
the brim, pass beneath the broad ligament on the same level, and downward, 
forward, and somewhat inward, about midway between the pelvic wall and 
the utero-vaginal junction ; and approach closely the anterior wall of the vagina, 
entering the base of the bladder about one inch below the cervix, and about 
two inches below the spine of the pubis (Polk) (Tandler and Halban) (Figs. 
158, 159, and 160). 

7. Rectum. — The rectum is apt to be loaded during pregnancy. This 
constipation is not so much due to the local uterine pressure, as to diminished 
peristalsis of the intestinal tract. During the early part and the last two weeks 
of gestation, constipation may alternate with diarrhea, from the irritation caused 
by the descent of the uterus. From interference with the blood-supply, hemor- 
rhoids may develop in the anus and rectum. 

8. Lower Extremities. — In the later months of pregnancy, oedema and vari- 
cose venous enlargements are often found, due to the obstruction to the return 
circulation (Fig. 475). Numbness, neuralgia, pains, cramps, and difficulty 
in walking may all result from the pressure of the uterus upon the sacral plexus. 

9. Pelvic Joints. — The inter-articular cartilages, especially that of the sym- 
physis, become softened and hyperemic, and more movable. The pelvic liga- 
ments also participate in the swelling and softening, and the synovial mem- 
branes are increased in size and said to be distended with fluid. Thus the com- 
ponent parts of the joints are pushed apart. Occasionally a case is so extreme 
that it is some time before the normal power of walking returns. The move- 
ment of the coccyx on the sacrum is important. This permits a bending back 
of the coccyx during labor, thus lending an efficient aid to the process, for the 
antero-posterior diameter of the pelvic outlet is materially increased (see Physio- 
logical Labor). 

10. Breasts. — Intimate sympathetic relations exist at all times between the 



118 PHYSIOLOGICAL PREGNANCY. 

breasts and the pelvic organs. Very early in pregnancy, usually about the 
second month, the mammae increase in size and become tender. This growth 
continues during pregnancy, and consists in the increase of connective and 
glandular tissues and fat. Blue veins become prominent and course over the 
breasts. Permanent stria appear at any time after the sixth month, due to 
stretching of the cutis vera, which permits the subcutaneous fibrous tissue to 
glisten through (Fig. 163). The nipples also enlarge and become sensitive. 
Their power of erectility is also increased. They are often covered with small 
branny scales. The areola become much enlarged, and darker in color from 
a deposit of pigment. This varies in degree with the complexion of the patient. 
In blondes it is sometimes scarcely perceptible, while in brunettes a great part 
of the breast may be involved. The areola, in addition to becoming dark, grows 
moist and swollen, while the series of tubercles increase in size in it around the 
nipple. Montgomery believes them to be closely connected with the lactiferous 
ducts, which can sometimes be traced to their summit where they open. These 
also increase in size and number with the progress of pregnancy. Outside the 
primary areola, in the later months of pregnancy, a secondary circle appears, 
called the secondary areola. This is composed of light spots scattered all 
around the periphery of the areola, which has shaded off from the deeper tones 
near the center. This change, too, is more marked in brunettes. Even as 
early as the third month, pressure on the breasts may force out a drop of 
serous-looking liquid. On microscopic examination milk and colostrum glob- 
ules will be detected, the latter being desquamated epithelial cells of the glands 
filled with oil-globules (Fig. 6). 

GENERAL PHENOMENA. 

1. Digestive System. — Nausea and vomiting are common disturbances in 
pregnancy. They are of all grades, from one simple attack at the time the 
woman first raises her head from the pillow, to repeated and severe vomiting 
spells, which occur from time to time during the day, and even in the night. 
These attacks sometimes begin with conception; more commonly, however, 
about the sixth week, lasting, as a rule, until the fourth month. The assump- 
tion of the erect position seems to cause this nausea, probably on account of the 
extra congestion brought on in the uterus by this position, thus increasing its 
irritability. These symptoms may result from various pathological conditions 
of the stomach or uterus, though the common and probably correct explanation 
is that the uterine fibers are stretched, and the nerves consequently irritated. 
Gastric indigestion may also occur, causing acidity, flatulence, heartburn, 
eructations, etc. The intestines seem to lack their normal peristaltic power, 
and that, together with the pressure of the growing uterus, renders constipation 
a common ailment of pregnancy, and one which should be relieved in order to 
prevent overburdening the kidneys. Diarrhea and excessive flatulence are 
at times not uncommon. The former may be of nervous origin, due to the 
mechanical irritation of the intestines by the growing uterus. Intestinal in- 
digestion is also very common, and may give rise to severe cramps. The ap- 
petite is apt to be capricious in early pregnancy, though it may change and 
become ravenous. There may be curious morbid cravings for various sub- 
stances, such as clay, chalk, slate-pencils, certain vegetable acids, etc. ; even dis- 
gusting articles may come into the category. 

2. Heart. — The existence of hypertrophy of the left ventricle has usually 
been taught as a physiological change in pregnancy to meet the extra demands 



LUNGS; LIVER; NERVOUS SYSTEM. 119 

made on the organism by the complex vascular arrangement of the pregnant 
uterus. The right ventricle and the two auricles were not believed to participate 
in this hypertrophy. Alfred Stengel and TV. B. Stanton, of Philadelphia, how- 
ever, controvert the old French notion that the heart becomes hypertrophied 
during pregnancy. By a series of carefully made tracings and readings of instru- 
ments devised for the measurement of blood-pressure, they show the correctness 
of Gerhardt's idea that the growth of the fetus, by pressing up the diaphragm, 
forces the apex of the heart upward and outward, and that this dislocation 
has been misinterpreted as a sign of hypertrophy. The tracings in twenty- 
six cases with careful measurements show this dislocation, which disappears 
after parturition. There is, however, a slight irregularity in the contour of 
the upper right margin of the heart, indicative of a slight hypertrophy of the 
right conus arteriosus. The murmurs which are heard in primigravidae are 
probably the result of a slight overaction of the right heart. Xo constant 
changes in blood-pressure could be demonstrated. 

3. Lungs. — The mother has to provide for the nourishment of her child 
and herself during pregnancy, therefore an extra quantity of blood must not 
only be circulated but purified. In this process the ehmination of carbonic 
acid gas must be increased. By mechanical pressure of the growing uterus 
the diaphragm is forced upward, lessening the longitudinal diameter of the 
respiratory space, although the lower thorax is somewhat broadened. This 
decrease in breathing space causes a certain amount of dyspnea, from the time 
of the beginning till the last weeks of pregnancy, when the uterus sinks again, 
and respiration and circulation are carried on with greater ease. In the early 
months cough and dyspnea, from sympathy, may cause a derangement of the 
respiratory organs, while the same is later caused by the growing uterus. These 
phenomena are most common in twin pregnancies, or in dropsy of the amnion. 

4. Liver. — Tiny fatty globules occur in the cells of this organ, varying in 
size from a pin's head to a millet-seed. De Sinety believes this change to be 
particularly associated with lactation, and to disappear after that period. This 
organ is also enlarged, as are the spleen and lymphatic glands, both the latter 
showing the same fatty changes. The enlargement of the spleen is due to the 
important relation existing between it and the quantitative change in the 
circulating blood. 

5. Nervous System. — The changes are purely junctional, and disappear 
quickly after delivery. The nervous system becomes more impressionable. 
The changes in the special senses are chiefly characterized by increased ex- 
citability. Great sensitiveness to bright light is developed; sometimes amaurosis 
and amblyopia are present. In cases of disturbed vision an examination should 
always be made for kidney disease; now and then there is a case of complete 
blindness associated only with anemia of the interior of the eye, and due to 
reflex contraction of the retinal artery. The nerves of taste become highly 
susceptible, and abnormal longing for acids or highly seasoned foods is not 
uncommon, with corresponding loathing for the ordinary articles of diet, such 
as milk, bread and butter, etc. The sense of smell becomes extremely keen. 
There is intolerance of loud sounds. Affections of hearing are quite uncommon, 
and when they do occur may be permanent, although usually temporary; as 
yet no explanation has been offered for them. There may exist, as in one case 
reported, some anomaly of the external auditor}- canal, as a hematoma. An 
increased delicacy of touch has been observed by Teuffel. The list of reflex 
nervous phenomena is manifold, and they are even seen, in a relatively slight 
degree, in voung women at the time of ovulation and the beginning of men- 



120 . PHYSIOLOGICAL PREGNANCY. 

struation. Much more will they be excited by the great change taking place 
in the maternal organism in pregnancy. 

Psychical Changes. — The disposition is in some cases entirely altered 
for the time being. Women otherwise amiable become peevish, fretful, irritable, 
and overanxious about their health and the condition of the offspring; and 
look forward with great dread to the pangs of labor. Others are affected in 
the opposite way, and become buoyant in spirits and unusually cheerful. This 
difference seems to depend largely on the intensity of the desire on the part of 
the mother for a child. The state of despondency which is so common, espe- 
cially in the first part of pregnancy, may lead to extreme melancholia and even 
develop into mania or dementia. This condition is seen particularly in patients 
of an intensely neurotic organization, in those with an hereditary taint of in- 
sanity, or with a history of hysteria or alcoholism. It may also follow severe 
mental shock in pregnancy. Unhappy marriages are also a fruitful cause of 
mania in gestation. Hysteria in pregnane}' offers an excellent illustration of 
the fact that the gravid state accentuates any defect, either physical or mental, 
in the patient. It was formerly thought that pregnancy exerted a beneficial 
effect on a hysterical woman, but this is erroneous. However, after its occur- 
rence the patient should be carefully watched and guarded. The physician 
should encourage her, and as is the case with the insane, special attention should 
be paid to the nutrition of the sufferer, and if necessary forced feeding should 
be instituted. Again, the patient should be treated with perfect frankness, 
and no deceit attempted. A careful physical examination before labor often 
gives the patient a feeling of confidence in her adviser. 

6. Blood. — Many conflicting views concerning the blood changes in preg- 
nancy have existed. The whole quantity is increased. It is generally agreed 
that there is a slight leucocytosis, but as to the increase or decrease in the number 
of red blood-corpuscles, there is still a dispute. Many authors believe their 
proportion to be decreased, but Ahlfeld, quoting the work of Reinl, Schroder, 
Ingerslev, Fehling, Mayer, Wild, MochnatschefT, and Frommel, declares that 
they are increased, as is the liquid element of the blood. The white cor- 
puscles, as has been indicated, are also slightly increased. The blood is deficient 
in albumin, but increased decidedly as to its fibrin element, as well as extractive 
matters. This fact explains the frequency of thrombotic affections in connection 
with pregnancy and delivery. This hyperinosis is increased also after labor, 
by the great quantity of effete matter thrown out into the circulation of the 
mother, to be disposed of by her emunctories. The circulating fluid of the 
pregnant woman is generally in a state more like the blood in anemia than 
plethora, and treatment should be applied accordingly. Objections to the 
anemia theory have been raised, on the ground that pregnancy is a physiological, 
and not a pathological condition. This is ideally true, but owing to the influence 
of many factors, such as civilization, climate, diet, and others, it must be ad- 
mitted that the pregnant woman is seldom in a state of perfect health; that 
her condition leans toward anemia and poverty of blood, and must be considered 
and treated accordingly. 

7. Urine. — As to the frequency of albuminuria in pregnancy, authorities 
differ, as well as to the amount of albumin commonly present; some declaring 
the percentage to reach 20 or 30. In physiological albuminuria there are no 
tube casts, nor any morbid symptoms. Albuminuria is far more common in 
labor than in pregnancy, and is explained at that time by the theory of renal 
anemia caused by the reflex vasomotor spasm of the renal arteries, resulting 
from the uterine contractions. It may occur early, before there is any possi- 



BLOOD; URINE; SKIN. 



121 






bility of renal venous stagnation from pressure, and it is then the result purely 
of reflex irritation. The intimate relation between the nerve ganglia of the 
pelvis and the venous supply of the kidney would explain this. The urine 
exhibits both quantitative and qualitative changes. The amount excreted in 
twenty-four hours is increased in quantity and decreased in specific gravity, 
due to the hydremic condition and the high arterial tension. There is an in- 
crease in the chlorides, and the phosphates and sulphates are decreased, on 
account of their use in the development of the fetus. Chalvet and Barlemont 
found a decrease also in the urea, uric acid, creatin, and creatinin; these may 
also pass over to the fetus (Leh- 
mann and Donne). (For Albumi- 
nuria and Pregnancy-kidnev see 
Part III.) 

8. Skin. — The functions of the 
glands of the skin — sebaceous, sweat, 
and hair follicles — are increased in 
gestation. Robert Barnes has stated 
that although the hair might have 
been falling out before conception, it 
seems to assume new vigor during 
this period. Pigmentary spots over 
the body are common. Patches of 
yellowish-brown color over the face 
are known as chloasma or the ' ' mask 
of pregnancy." The abdomen and 
breasts are also darkly pigmented in 
areas. The linear albicantiae are very 
marked. Many women will have on 
the abdomen a brown area of about 
two fingers' breadth, extending from 
the mons veneris to the umbilicus, 
which it sometimes surrounds, and 
beyond to the xiphoid cartilage. 
This band is more distinct below 
than above the navel (Fig. 163). 
The circle around the latter is known 
as the "umbilical areola" (Fig. 163). 
The mammary areolae, both primary 
and secondary, have been described. 
These pigmentations undergo many 
variations in extent and degree in 

different patients. Brunettes show them more plainly than blondes. The pig- 
mentation of the vulva, as a sign of early pregnancy, has also been referred to. 
These deposits seldom disappear entirely, but they are less after labor. Abdomi- 
nal striae, or silvery streaks or white lines, are seen on the abdominal wall as the 
result of the first pregnancy ; and it is not uncommon to observe the formation 
of new ones in subsequent pregnancies (Fig. 163). They may also be seen on 
the hips, thighs, and breasts (Fig. 163). These markings are at first of a pinkish 
or bluish-red tint, but after parturition they become white or pearl-colored. 
They are due to the partial rupture and atrophy of the connective tissue of 
the deep layers of the distended skin. They are not peculiar to pregnancy, 
but occur even on men after the skin has been subjected to much stretching, 




Fig. 163. — Pregnancy at the Thirty- 
eighth Week showing Stride and Pig- 
mentation of Thighs, Abdomen, and 
Breasts, and Right Lateral Obliquity 
of the Uterus. — {From author's photo- 
graph at the Emergency Hospital.) 



122 PHYSIOLOGICAL PREGNANCY. 

as in ascites, etc. The skin covering the umbilical depression, in the first 
three months of intrauterine gestation, is drawn inward and downward, by 
the traction on the urachus, the ligament following the descent of the bladder 
occasioned by the early sinking of the uterus. The navel now presents a pit 
or depression. This causes a dragging sensation; when the uterus begins to 
rise out of the pelvis, the navel resumes its former appearance. During the 
fourth, fifth, and sixth months the depression becomes progressively shallower, 
till at the seventh it is on a level with the skin, the ring being at the same time 
dilated so as to admit the end of the finger. During the last two months the 
umbilicus may actually form a protuberance, and this appearance is known as 
"pouting of the navel." Not infrequently, if the woman overexert herself, 
an umbilical hernia will be formed. 

9. Gait. — The gait of a pregnant woman undergoes change, for in order to 
preserve the center of gravity, the head and shoulders must be thrown back- 
ward. Short women show this change most markedly. 

10. Delay of Bony Repair. — On account of the drain by the fetus on the 
mother's osseous elements, fractured bones unite slowly. 

11. Cranial Cavity. — Between the skull and the dura mater irregular bony 
deposits have frequently been found in the autopsies on pregnant women. 
Rokitansky called these lamellae "'puerperal osteophytes," and believed them 
to be the result of a physiological, and not a pathological, process connected 
with pregnancy; but the exact explanation of this phenomenon has not 
yet been furnished. These lamellae are of irregular form and consist of calcium 
carbonate, a little organic matter, and a small quantity of phosphates. They 
are not peculiar to pregnancy. 

12. Temperature. — The temperature in pregnancy remains unchanged. 
Some authorities, however, believe it to be lower in the morning than later 
in the day. 



III. THE DIAGNOSIS OF PREGNANCY. 

Importance. — The importance of expert diagnosis in cases of suspected 
pregnancy is very apparent. There are no mistakes in a physician's experience 
so hard to live down as those made in this domain of medicine, and none that 
excite harsher criticism, or greater ridicule for the diagnostician. Apart from 
these less important considerations, it must be remembered that the knowledge 
of the existence of pregnancy is often of the greatest importance to the life of 
the patient, both in the field of medicine and that of surgery. A physician can 
sometimes render incalculable service by being able skilfully and honestly to ex- 
clude the possibility of pregnancy; and, on the contrary, he can do great harm 
and cause much misery by expressing the opposite opinion in a case innocent 
of this condition, the opinion being based on a careless or ignorant interpreta- 
tion of the signs at his disposal. The medico-legal value attaching to this 
question is often important. 

A number of symptoms and signs taken together give certain evidence of 
the presence of pregnancy; and single signs, especially in the latter part of preg- 
nancy, render the diagnosis probable or even positive. The physician, how- 
ever, will always do well to be reserved in the expression of his opinion, if there 
is any doubt as to the certainty of the condition. The diagnosis depends upon 
the physician's ability to group the symptoms in the order of their importance, 



THE DIAGNOSIS OF PREGNANCY. 



123 



and upon his familiarity with all the methods of examination. The difficulties 
of diagnosis will be considered later, under the head of differential diagnosis. 
Mistakes should be avoided by the greatest care in the details of the examina- 
tion. With all these precautions, there are on record numerous cases which 
exemplify the striking errors of eminent specialists. 

The physical signs are of far more importance and value than the symptoms, 
and are obtained by means of sight, touch, and hearing. There is much room 
for deception in the patient's account of herself, for she may intentionally or 
unintentionally misrepresent one or all of her symptoms. But the informa- 
tion which is obtained by inspection, palpation, percussion, and auscultation, 
lacks the uncertain element always present in the personal history, and gives 



\ 




Fig. 164. — Position of the Fingers for Vaginal Examinations and Manipulations. 

— (Photograph.) 



data that can be relied upon. Upon the period of the pregnancy will depend 
to a certain extent the satisfactory results of the examination. For the prepara- 
tion and posture of the patient for the examination see Obstetric Examina- 
tion. 

Classification. — The symptoms and physical signs of pregnancy may be 
conveniently classified as: (1) Uterine; (2) vaginal; (3) abdominal; (4) mam- 
mary; (5) fetal; (6) sympathetic and reflex; (7) due to pressure and congestion; 
(8) cutaneous; (9) individual and subjective. 

1. Uterine. — (1) Cessation of Menstruation. — This, as a general rule, 
is the first warning of pregnancy to women who have been exposed to impregna- 
tion. It is not a perfectly trustworthy symptom, for it may occur in various 



124 



PHYSIOLOGICAL PREGNANCY. 



diseases and conditions. However, when occurring in healthy women who 
have previously menstruated regularly, it is strongly presumptive of pregnancy, 
and it is of great practical value, as it probably offers the most reliable datum 
for predicting the date of confinement. Nevertheless, certain errors must 
be guarded against in relation to this symptom, for various chronic diseases, 
such as tuberculosis, anemia, syphilis, and some acute affections, such as diph- 
theria, pneumonia, and dysentery, cause a cessation of the menstrual flow, 
either permanently or temporarily. Change of climate ; exposure to cold ; mental 
emotions; general debility; excessive desire to become pregnant, as in the newly 
married; or a fear of becoming so in the unmarried who have exposed them- 
selves to impregnation — all these causes may be instrumental in bringing about 
a cessation of the menses. Pregnancy may occur in cases in which menstruation 
is absent, as in women during lactation; while it has been known to occur in 
young girls before this function was established. A few authentic cases -are 
recorded of the occurrence of conception after the climacteric; and, again, of 




Fig. 165. — Right and Left Halves of a Frozen Section of a Uterus at Two and a 
Half Months, showing Changes in Shape and Density of the Uterine Walls 
and Thick Decidua. — (After Pinard.) 



the continuance of the menstrual periods during pregnancy, or of what is thought 
to be menstruation by the patient. At the same time there may be hemorrhages 
due to pathological conditions of the internal genital tract, as from the vagina, 
mucous membrane of the cervix, decidua, chorion, polypi, or placenta praevia. 
If menstruation pure and simple does occur during pregnancy, it may be easily 
explained by the anatomical condition of the growing uterus with its con- 
tents. (See Development of the Ovum, page 46.) 

(2) Changes in Volume, Shape, and Position. — In palpating the uterus 
in search of the signs of pregnancy, the bimanual or conjoined method 
is preferable to simple palpation with one hand, or vaginal touch, as it is called; 
and of the bimanual methods, the ab domino- vaginal is most useful, and most 
often used, but the abdomino-rectal is occasionally of value, especially in 
primigravidse. The physical signs arising from the progressive growth of 
the uterus, causing alterations in volume, shape, and position of the organ, 
have already been described under "The Local Changes Produced by Preg- 



THE DIAGNOSIS OF PREGNANCY. 



125 



nancy," page 91, and familiarity with these changes should be acquired by the 
student. At the same time, other causes of uterine enlargement may simulate 
pregnancy, as subinvolution, inflammation of the uterus and peri-uterine tis- 
sues, and intramural tumors of the organ. (See Differential Diagnosis of 
Pregnancy.) 

(3) Changes in Consistency. — (a) Progressive softening of the cervix, 
which begins at the external os, and gradu- 
ally extends, until by the end of pregnancy 
the whole cervix is included in a velvety 
softness due to serous infiltration. Begin- 
ning softening can often be detected as 
early as the second or third week; on this 
change Goodell founded the rule that, 
when the cervix is as hard as the tip of 
one's nose, pregnancy presumably does not 
exist; but if it be as soft as one's lips, 
pregnancy is probable. (6) Softening and 
compressibility of the lower uterine third 
constitute He gar's sign. This is of great 
value, and has been observed by the sixth 
or eighth week. It consists in alteration 
in the consistency and shape of the region 
of the uterus situated just above the cervix 
— a change that is most striking in the 
middle division of the lower uterine third. 

This part of the uterus seems at times hardly thicker than ordinary cardboard, 
and it would almost appear as if the fundus and the cervix were separate tumors. 
The shape is also changed, the lower uterine third widening abruptly above 




Fig. 166. — First Method of Eliciting 
Hegar's Sign of Pregnancy. — 

{Sonntag.) 





Fig. 167. — Second Method of Eliciting 
Hegar's Sign of Pregnancy. — {Sonntag.) 



Fig. 168. — Third Method of Eliciting 
Hegar's Sign of Pregnancy. — {Sonn- 
tag.) 



the cervix, and not gradually, as in the normal pear-shaped uterus. These 
alterations are far more difficult to recognize in women who have already borne 
one or more children, but when well marked are absolutely indicative of a 
pregnant uterus. The detection of these changes requires a certain degree of 



126 



PHYSIOLOGICAL PREGNANCY. 



/ 



'*& 










Fig. 169. — Position of the Two Hands in the Bimanual Examination for the Diag- 
nosis of Pregnancy. 





Fig. 170. — Bimanual Examination with 
the Hand on the Fundus and One 
Finger in the Left Lateral Vaginal 
Fornix. 



Fig. 171. — Bimanual Examination with 
the Hand on the Fundus and a 
Finger in Each Vaginal Fornix. 



DIAGNOSIS OF PREGNANCY. 127 

skill in the performance of the bimanual examination, and also of familiarity 
with the sensations communicated to the finger by the non-pregnant uterus 
of women who have never borne children, by the non-pregnant uterus of women 
who have borne several children, and also by the uterus altered by certain 
pathological conditions. Method of examination: (a) In a patient whose abdom- 
inal walls are lax and thin and whose vagina is room}', the two fingers are intro- 
duced into the vagina, and passed high up behind the cervix, while the other 
hand presses down into the abdomen from above and behind the pubes (Fig. 
169). (b) But if the fundus should be decidedly anteflexed, the vaginal finger 
should be passed up in front of the cervix, while the external hand presses down 
the fundus (Fig. 169). (c) Where the favorable conditions of lax abdominal 
parietes and capacious vagina are not present, the index-finger is passed into the 
rectum, while the thumb is inserted into the vagina in front of the cervix. The 
other hand, in the mean while, exerts pressure on the abdomen behind the 
pubes. (d) Still another method is feasible: with the internal hand in the same 
position as in the last method, the external hand presses the fundus uteri down- 
ward. Sometimes the cervix is pulled down by a tenaculum. Between the 
second and fifth months of pregnancy 30 per cent, of the cases of pregnancy 
may be recognized by this sign. Anesthesia is rarely required in order to 
conduct these examinations. There are diseased conditions of the wall of the 
uterus in which this sign cannot be obtained, even though pregnancy exists. 
(c) Consistency of body of uterus. Pregnancy changes the rigid, firm, inelastic 
condition of the non-pregnant uterus, to an elastic, resilient state which in- 
creases with the advance of pregnancy, until the fetus is contained in a flexi- 
ble, elastic-walled cavity. The peculiar sensation imparted by a uterus enlarg- 
ing from pregnancy is most characteristic (Fig. 165) (see Local Changes Pro- 
duced by Pregnancy). 

(4) Intermittent Contractions, Braxton Hicks's Sign. — These may be 
detected by palpation as early as the fourth month. If the hand is placed 
in full contact with the abdominal contour of the uterus, friction and pressure 
being absent, and retained there for from five to twenty minutes or less, the 
gradual relaxation or contraction of the uterine musculature will be felt. These 
contractions as a rule occur every five or six minutes, while the duration of each 
contraction is from two to five minutes. Braxton Hicks says that " if an abdom- 
inal tumor thus changes in density and hardness we may be sure that the tumor 
is the uterus." But Lanier has shown that the same sensations of intermittent 
contractions may be obtained from a distended bladder. Soft fibroids of the 
uterus also give these sensations, as well as the uterine efforts to expel blood- 
clots, polypi, or retained menses. However, when taken in connection with 
the other signs of pregnancy, this sign is of great value. 

(5) Uterine Murmur, Souffle, or Bruit. — This sound was also wrongly 
called the placental souffle or murmur, or bruit placentaire, by those who 
regarded it as due to blood rushing through the placental sinuses. Again, it 
has been called abdominal souffle by others, who think it due to pressure of 
the pregnant uterus upon the large abdominal vessels. The sound is a single 
murmur, synchronous with the first sound of the maternal heart. Its quality 
varies, sometimes being gentle, murmuring, blowing or musical, resembling 
very much the sound produced by pronouncing "voo" in a low tone. At other 
times it is harsh, loud, and scraping; while again it may be sibilant, or sonorous. 
Its rhythm may be continuous and regular, corresponding with the mother's 
pulse, or it mav be distinctly irregular. After being once heard, it may dis- 
appear for a few minutes or for several days, and its position is very apt to shift. 



128 PHYSIOLOGICAL PREGNANCY. 

Sometimes it will persist in a circumscribed spot; again in two spots, one on 
either side of the uterus; or, again, it will be diffused over the whole anterior 
abdominal region. The weight of authority is to the effect that this sound 
originates in the uterine blood channels. The murmur has been observed several 
days after the birth of the placenta, and no legitimate proof of its origin in 
the abdominal vessels has been offered. Aside from its variation in position, 
it frequently varies in duration, intensity, tone, and pitch. It is most frequently 
detected at the lower part of the abdomen, and this would of necessity be the 
case in the early part of gestation. Feebleness or death of the fetus has no 
effect upon it. Only an expert can recognize it before the sixteenth week. 
It is not a positive sign of pregnancy, for similar sounds may be heard in ovarian 
or uterine tumors of large size. In labor it is stronger at the beginning of a 
pain, ceasing altogether at its height, and returning again as the pain declines. 

(6) Uterine Fluctuation, Rasch's Sign, may be detected as early 
as the second month of pregnancy. As in ballottement, two fingers of the 
left hand are introduced into the anterior vaginal fornix, while the right hand 
firmly grasps the fundus. Tapping by the fingers of the external hand will 
transmit an impulse to the internal fingers, the wave being transmitted through 
the liquor amnii. This sign, considered by many to be of diagnostic value, must 
not be confounded with Hegar's. 

(7) Asymmetry of the Corpus Uteri. — The fact has often been noted 
that at a very early period of pregnancy the corpus uteri is asymmetrical, one 
side being thicker than its fellow; while the bulging portion is marked off from 
the rest of the corpus by a furrow (Fig. 165). This bulge may appear upon any 
portion of the body of the organ. There is also a difference in the density of the 
two portions, the prominence being dense and firm, while the rest of the corpus 
feels elastic (Fig. 165). Braun-Fernwald, who has studied this sign with great 
care, believes that this asymmetry of the uterus is a necessary result of the 
implantation of the ovum upon one side of the uterine cavity.* Many authori- 
ties believe that this is the earliest and most constant uterine sign of pregnancy. 

(8) Uterine Pulse. — The claim has been made that the pulse of the 
uterine artery, which is ordinarily impalpable, may be recognized early in preg- 
nancy. To elicit this sign the organ should be depressed and the artery felt 
for high up in the lateral cul-de-sac. 

2. Vaginal. — (1) Purplish Discoloration of the Vaginal and Vulval 
Mucous Membranes; Jacquemier's Sign: Congestion of the vulval and 
vaginal blood-vessels causes, as early as the sixth, but frequently not until 
the twelfth week, first a violet or light blue, and, as pregnancy advances, a 
purplish or deep blue hue of the mucous membrane (Fig. 7). In the vulval 
canal the sign is most intense just below the urethral orifice. This is one of 
the probable signs of gestation. It is true that pelvic inflammation and tumors 
may produce the sign, but rarely to the degree caused by pregnancy. (2) 
Increased Secretion: The vaginal discharges are normally increased during 
pregnancy, coincident with the hypertrophy of the mucous membrane, and a 
condition may arise in the perfectly healthy pregnant woman which would be 
known in the non-gravid subject as catarrhal vaginitis. This is especially 
common in the latter half of gestation. The discharge is whitish and may be 
profuse enough to alarm the patient. Endo trachelitis may also be the cause 
of a vaginal discharge during pregnancy. (3) Temperature: The sensation 
of increased heat in the genitalia is an important sign. It is due to the augmented 
blood supply to those parts, to the pathological condition of vaginitis, or to 
*" Wien. klin. Woch.," 1899, No. 10. 



THE DIAGNOSIS OF PREGNANCY. 129 

congestive diseases of the pelvic viscera. (4) Vaginal Pulse; Osiander's 
Sigx: During and after the middle third of gestation a distinct pulsation of 
the vaginal arteries, due to local high arterial tension, may be made out; while 
not a positive sign of pregnancy, this is a probable one, and is of value in con- 
junction with others. Non-pregnant conditions, as fibroids and pelvic inflam- 
mations, may give rise to the same sign. 

3. Abdominal. — (1) Progressive Enlargement: In the beginning of 
pregnancy there is hypogastric flattening, due to the sinking of the uterus from 
its increased weight. Later the abdomen enlarges, becoming the shape of a 
pear, with the smaller end downward. The enlargement first becomes notice- 
able at the fourth month. The tumor is then in the median line, but later tends 
to the right. The uterus rises about two fingers' breadths every four weeks. 
At the end of the third month the fundus uteri is about on a level with the top 
of the symphysis. During the fourth month it occupies the hypogastrium ; 
at the fifth it is half-way between the symphysis and umbilicus; by the sixth 
it is at the umbilicus or just above; by the seventh it is half-way between the 
umbilicus and ensiform cartilage. It reaches the ensiform by the eighth month, 
where it remains for about two weeks, then sinks a trifle in the last two weeks 
of pregnancy. It is hardly necessary to state that this is merely a doubtful 
sign, as abdominal enlargement closely simulating pregnancy may be due to 
many pathological conditions, such as uterine fibroids, excessive deposition of 
fat in the abdominal walls, tympanites, ovarian cysts, and other abdominal 
tumors. (2) Pigmentation (Fig. 163): This, as I have repeatedly demonstrated 
in the clinic, is in some women entirely absent, thus giving us only a doubtful 
sign of pregnancy. It has also been observed in cases of ovarian irritation, 
at the menstrual periods, and in myomata of the uterus. (3) Stride (Fig. 163) : 
They give us only an uncertain sign of pregnancy, as they may result from 
excessive non-pregnant enlargement of the abdomen. They are even found 
in the male. (4) Abdominal Ballottement: During the middle third of preg- 
nancy, by placing the hands upon both sides of the abdomen, where the muscles 
are not too tense, the fetus may be passed back and forth between the two 
hands by a series of gentle but decided pushes or taps. This is known as ab- 
dominal ballottement. A tense, resisting abdominal wall, or one loaded with 
fat, will obscure all the signs of -pregnancy obtainable by palpation. (5) Fluc- 
tuation: In the last third of pregnancy, if the flat of one hand be placed upon 
one side of the abdomen, while the opposite side is lightly tapped, distinct 
fluctuation may be elicited in some cases. This is naturally an uncertain sign. 

(6) Changes in the Percussion-note and Umbilicus: Percussion should 
not be neglected in the examination for pregnancy. This method will yield 
only negative signs before the end of the third month. In practising percussion 
in early pregnancy, care should be taken not to mistake the flatness produced 
by a distended bladder for a pathological tumor of the pelvis or abdomen. 
Generally the dullness of the uterine body can be detected, surrounded on three 
sides by the tympanitic intestines. Now and then, however, a few intestinal 
coils will interpose themselves between the uterus and the anterior abdominal 
wall, and give a tympanitic resonance in response to tapping. (For changes 
in the umbilicus, see page 122.) 

4. Mammary. — The physical signs include (1) general enlargement; (2) 
prominence of*the veins; (3) pigmentation, forming primary and secondary 
areolae; (4) enlargement of the tubercles of Montgomery; (5) prominence, erec- 
tion, turgescence, and bran-like scales of the nipple; (6) formation of striae; 

(7) secretion of colostrum. The presence of secretion is the most valuable of 

9 



130 PHYSIOLOGICAL PREGNANCY. 

the foregoing signs, and in primigravidous women it is a probable sign of gesta- 
tion. In multigravidse it becomes uncertain, though the suppression of milk 
in a nursing woman has considerable importance in corroborating other signs. 
Taken alone, these signs are not trustworthy; their absence does not prove 
the non-existence of pregnancy ; they should be supplemented by more positive 
signs. Uterine or ovarian diseases may be accompanied by many of them, or 
they may persist a long while after delivery. (See Local Changes Produced 
by Pregnancy, page 91.) The advantage of mammary changes over other 
objective signs consists in their early and almost inevitable occurrence, and 
in the possibility of examining the patient's breasts without rousing her sus- 
picion. 

5. Fetal. — (1) Quickening: This term arose from the former erroneous 
notion that at the time when the mother became conscious of the spontaneous 
movements of the fetus, life was imparted to the fetus. The active fetal move- 
ments are generally first felt by the mother at the end of the sixteenth week. 
Although perceived by the patient at such a comparatively late period, they 
really occur very early in embryonal existence, i. e., as soon as the muscular 
tissue is sufficiently developed to contract. The commonly accepted idea is that 
they are first perceived by the mother when the uterus has expanded suffi- 
ciently to come in contact with the anterior abdominal wall, and thus the fetal 
movements are transmitted to her sensory nerves. They have been compared, 
when first felt, to the fluttering of a bird imprisoned in the hand. With ad- 
vancing gestation these movements increase in vigor, and may even become 
painful, consisting of sharp, short strokes, or kicks. They greatly increase after 
fasting, and just before fetal death by asphyxia. They may cease entirely, 
and the fetus still remain in perfect condition, although their sudden and com- 
plete cessation is often coincident with the death of the child. In some cases 
these movements have never been detected by either mother or physician, and 
yet at term a perfectly healthy child has been delivered. It has been suggested 
that in such cases the movements were not absent, but took place during sleep, 
and so were unperceived by the mother. Pathological conditions, such as 
hydramnios and ascites, may either partly or wholly obscure these motions. 
This sign, in the light of a subjective symptom, is open to many errors, for 
irregular muscular contractions of the abdominal muscles, the peristalsis of the 
intestines, especially when the latter are full of gas, or a wandering kidney, 
may cause similar sensations. However, some little value attaches to it from 
the fact that its first occurrence furnishes a certain datum for the calculation 
of the time of confinement. When the physician himself feels, or sees, or hears 
these movements, they constitute a sure sign of the existence of pregnancy, 
and of the viability of the child. No other movement, normal or abnormal, 
occurring in the abdomen can ever give a like sensation to the hand of the 
examiner. After their first detection by the physician, and as gestation ad- 
vances, they may not only be felt but also seen or heard. Prior to the fourth 
month, the methods of bimanual palpation, or vaginal stethoscopy, may elicit 
them now and then, but after that time abdominal palpation is used. Among 
these movements should be included fetal hiccough. 

(2) Palpation of the Fetus. — About the middle of pregnancy the 
uterus will have become so elastic, thinned, and compressible that we are able 
upon palpation to make out the fetus, which is now large enough Ho be recognized 
by the abdominal touch. At the end of pregnancy this is of great value in 
detecting the various positions of the child. Movements of the fetus may be 
detected by palpation in the fifth or sixth months. (See Quickening.) These 



THE DIAGNOSIS OF PREGNANCY. 



131 



movements may be seen by the eye or felt with the hand. In examining for 
fetal movements, the palm of the hand is placed upon the abdomen, and steady 
downward pressure is kept up for some moments. Should the movements not 
be felt, pressure, or a series of gentle raps with the other hand about the first, 
will generally suffice to produce them. 

(3) Heart Sounds. — Mayor, of Geneva, in 181 8, discovered that upon 
applying the ear to the abdomen of the pregnant woman the fetal heart sounds 
could be heard, and thus the most important sign of pregnancy was brought 
to light. Kergaradec, of Lausanne, ignorant of the discovery of Mayor, an- 
nounced the same fact three years later, in 1821. The discovery was accidental 
in each case. Auscultation in obstetrics furnishes the only sign of pregnancy 




Fig. 172. 



•Internal Ballotement at the Sixth Month. 

Posture. 



Patient is in the Reclining 



which, in itself, and in the absence of all others, is perfectly reliable; namely, the 
heart sounds of the fetus. These sounds are first heard about the middle of the 
fourth month. They consist of two sounds or beats, a first sound and a second 
sound. These two are separated by a slight interval, the first sound being the 
louder, longer, and more distinct; the second shorter, less loud, and less dis- 
tinct, often being almost inaudible. The usual simile used in illustration is the 
ticking of a watch heard through a pillow. While the rapidity of this sound 
continues the same throughout pregnancy, the intensity and strength steadily 
increase. The rapidity and intensity of the fetal heart sounds may be 
temporarily increased or diminished; thus, the movements of the child may 
send the heart up several beats per minute, and at the same time increase its 



132 PHYSIOLOGICAL PREGNANCY. 

intensity. On the other hand, during labor and after the escape of the liquor 
amnii, the contractions of the uterine walls may greatly reduce their intensity, 
and this fact is one indication for interference in prolonged or retarded labors. 
The position, or point of the greatest intensity, of the fetal heart sounds will 
vary with the position of the child in the uterus. In head presentations 
the fetal heart is most frequently heard at a point half-way. between the um- 
bilicus and the left anterior superior spine of the ilium, the reason for this being 
that the most frequent position of the fetus is with its back anterior and directed 
a little to the left side of the mother. The next most frequent site will be on 
the same level, but upon the opposite side of the median line. In breech cases, 







v 





; i 


/ 


i 



Fig. 173. — Auscultation of the Fetal Heart with the Phonendoscope. Method 
of raising the fundus of the uterus upward and forward so as to bring the uterine 
walls close to the abdominal parietes and thus intensify the fetal heart-sounds. 
— (Front a photograph at the Emergency Hospital.) 

on the other hand, the fetal heart is heard best above the umbilicus, to one 
or the other side of the median line, according to the position of the child, the 
sound of the heart being naturally heard with greatest intensity at that point 
where the back of the child touches the uterine wall. Like all vascular sounds, 
it is transmitted better through solid than fluid media. When the fetal heart 
sounds are heard distinctly, they furnish an absolute and certain physical sign 
of pregnancy. It is the surest sign, and is readily recognized after the fourth 
month. It is entirely beyond the control of the patient. The only other sign 
of equal value is recognition of the fetus by abdominal or vaginal palpation. 
The fetal heart not only makes it positive that pregnancy is present, but also 
that the child is living. The fact that it is not heard, however, does not nega- 



THE DIAGNOSIS OF PREGNANCY. 133 

tive pregnancy, for the fetus may be dead, or the sounds for a time inaudible; 
the maternal abdominal walls may be very thick and fat; the fetal back may 
be posterior; the intestines may be full of gas ; hydramnios may be present. The 
rate of the fetal heart sounds and that of the mother's do not correspond. The 
fetal heart beats from 130 to 150 times a minute. It is slightly more frequent 
in small than in large children. Attempts have been made from this to pre- 
dict the sex of the child, since males are usually larger than females. When 
the sounds are distinctly heard, but the uterus is too small to contain a fetus 
old enough to make them, there is a strong indication of extrauterine pregnancy. 

(4) Ballottement. — In the latter part of the fourth month, or the first 
part of the fifth, ballottement may be practised. The preferable position for 
the patient is reclining, midway between standing and sitting, although either 
of the latter positions may be assumed (Fig. 172). Ballottement is the earliest 
of the positive signs, as it may be obtained from the fourteenth or fifteenth 
week till within six or eight weeks of delivery. In practising ballottement 
the examining finger is introduced into the vagina and suddenly pushed up 
against the lower portion of the uterus. The impulse thus generated is trans- 
mitted to the fetus, which bounds upward and then falls back upon the ex- 
amining finger (Fig. 172). This is a physical sign of pregnancy which, when 
clearly made out, is infallible; for although an anteflexed fundus, or a calculus 
in the bladder, and some other pathological conditions, may give rise to very 
similar sensations, still, in such cases, no other signs of pregnancy will be present. 
Before the end of the fourth month the fetus is too small to give resp'onse to the 
digital impulse, and after the seventh month the child is relatively too large, 
so nearly filling the uterine cavity that it cannot be moved about so freely as 
formerly. In multiple pregnancies, and in deficiency of the liquor amnii, the 
sign will be absent for the same reason. Neither shoulder nor breech presenta- 
tions, as a rule, respond to this test. 

(5) Umbilical Murmur, or Souffle, consists of a slight blowing murmur, 
synchronous with the fetal heart sounds, and most distinctly heard in their 
vicinity. The sound can be detected in about 15 per cent, of all the cases of 
pregnancy, and is thought to be due to pressure upon the umbilical cord, from 
its coiling, or from some form of compression. Its position varies with the 
presentation of the child. Its practical value is nil. 

6. Sympathetic and Reflex. — (1) Nausea and Vomiting; Morning Sick- 
ness. (See Digestive System, page 118.) (2) Sympathetic Disturbances 
of the Nervous System, such as changes in disposition and taste, have no 
value in the diagnosis of pregnancy and have been described under "The Phe- 
nomena of Pregnancy." 

7. Pressure and Congestion. — The neighboring organs are disturbed by the 
growth and development of the uterus, these disorders depending partly upon 
hyperemia and partly on mechanical pressure. (1) Bladder: The bladder 
becomes irritable; during early pregnancy frequent micturition, incontinence, 
and vesical tenesmus are common symptoms. In a woman previously free 
from vesical irritation, this symptom, in conjunction with cessation of men- 
struation, we have frequently found most valuable, and we would class it as 
a probable sign. In our experience, persistent vesical irritation is the most 
valuable of the very early symptoms. (See Bladder, page 117.) (2) Rectum : 
In the latter months fecal accumulations in the lower bowel cause much irrita- 
tion and discomfort. (3) Lower Extremities: Sciatica, oedema, and varicosi- 
ties are frequently observed as the result of pressure. 

8. Cutaneous. — Pigmentation of the forehead and cheeks, in the form of 



134 PHYSIOLOGICAL PREGNANCY. 

dark brown patches termed chloasmata, or blotches, is found in some pregnant 
women, especially brunettes. These, as well as dark circles about the eyes, 
are most uncertain signs, and are found occasionally during menstruation and 
in ovarian and uterine disease. Pigmentation and striae of the breasts and 
abdomen have already been classified under Mammary and Abdominal signs. 

9. Individual and Subjective. — A woman who has borne many children 
is often better able to tell when she has conceived than is the most skilful diag- 
nostician. Under these circumstances the truth is reached by individual or 
idiosyncratic phenomena. Dismissing as entirely untrustworthy the existence 
of peculiar sensations during the impregnating coitus, there can be no doubt 
that individual signs may appear within a few days after conception. One 
woman under these circumstances experiences a characteristic vertigo, another 
nose-bleed, a third pruritus vulvae, a fourth swelling and tenderness in the veins 
of the lower extremities (in cases of past puerperal phlebitis). The various 
sensations complained of have an individuality which is never noticed on any 
other occasion. 

SUMMARY OF THE DIAGNOSTIC SIGNS OF PREGNANCY. 

The symptoms and signs of pregnancy may be divided into three classes: 
(I) Doubtful; (II) probable; (III) certain. The first may occur in the male. 
The second have to do only with the genitals of the woman. The third are 
produced only by the presence of the fetus. (I) To this class belong all those 
signs dependent partly on pressure, and partly on blood changes, or alterations 
in nervous activity. These are nausea, vomiting, fainting, varicosities, oedema, 
headache, toothache, and backache, also pigmentation of the skin, frequent 
micturition, and "longings" or "cravings." These signs are almost valueless; 
save in cases of multiparae, who, having never suffered otherwise from any of 
these symptoms, have noted a certain syndrome in every pregnancy. In some 
instances nausea, vomiting, and depressed spirits have occurred almost im- 
mediately after a fruitful coitus, so that the patient was aware of her condition 
before the cessation of the menses. (II) The next group proceeding from the 
female genitalia is of more importance and comprises : (a) cessation of the menses. 
(b) The changes in the color of the vulva, vagina, and uterus; the palpable 
pulsation in the vaginal fornices; the increasing size of the uterus; the rounding 
of the external os; and the softening, elasticity, and thinning of the uterus just 
above the insertion of the sacro-uterine ligaments, (c) The uterine souffle. 
(d) Breast changes, (e) The striae and umbilical changes. (Ill) The certain 
signs are: (a) Mapping out of the fetus. (6) Fetal heart sounds, (c) Move- 
ment of the child as felt by the examiner, (d) Umbilical murmur. 

To recapitulate: 

I. The Positive or Certain Signs are : (1) Mapping out outlines of the whole 
or parts of the fetus by palpation. (2) The fetal heart sounds. (3) Move- 
ments of the fetus, active or passive; to be regarded only when confirmed 
by an experienced observer. (4) Vaginal and abdominal ballottement. (5) 
The umbilical or funic murmur, in the 10 or 15 per cent, of cases in which it is 
present, is also a certain sign. 

II. The Probable Signs are: (1) The progressive enlargement of the uterus 
and its characteristic alterations in shape. (2) The compressibility of the 
lower uterine segment, Hegar's sign. (3) Intermittent uterine contractions, 
Braxton Hicks 's sign. (4) Changes in consistency of enlarging uterus. (5) 
Changes in consistency and color of vagina and cervix. (6) Uterine murmur. 



THE DIAGNOSIS OF PREGNANCY. 135 

(7) Cessation of menstruation. (8) Mammary signs, as enlargement of breasts 
and Montgomery's tubercles. (9) Pigmentation and secretion. 

III. The Uncertain or Doubtful Signs are: (1) Changes in size and shape 
of abdomen as well as pigmentation, striae, fluctuation and changes in the per- 
cussion note. (2) Sympathetic and reflex disturbances, as nausea, vomiting, 
alterations in taste and disposition. (3) Pressure and congestive signs, as 
irritable bladder or rectum, pain, and oedema in lower extremities. (4) Cu- 
taneous signs, as chloasmata on the forehead and cheeks and dark circles under 
the eyes. Pigmentation and striae of the abdomen and breasts have already 
been classified. 

The signs of pregnancy may, finally, be classified according to the time at 
which they appear. First month : The abdominal changes begin to appear. 
There is cessation of menstruation. It is early for the manifestation of morning 
sickness, and for changes in the breasts, though they may take place. The 
cervix begins to soften from the very first. Second month : Hegar's sign may 
now be obtained. There is pulsation in the vaginal vault. This month is 
the ordinary time for the beginning of mammary and gastric changes. Depres- 
sion of the umbilicus persists, and the uterus sinks, while the abdomen is flat. 
Third month : The umbilicus is still depressed, and the uterus sunken till the end 
of this month, when it begins to rise. The softening of the cervix increases 
in extent. Gastric and mammary changes continue. Fourth month: The 
uterus begins to rise, consequently the depression at the navel commences to 
fill out, and the abdomen to become prominent. The breast changes increase, 
but as a rule the gastric disturbances are allayed. At the end of the month 
the heart sounds may rarely be heard. The uterine murmur is present. The 
patient sometimes feels quickening, and the examiner may detect fetal move- 
ments, as well as uterine contractions. Fifth month : Normally at this time 
the gastric disturbances have entirely ceased, and the appetite and digestion 
are excellent. The abdomen is plainly increased in size, and quickening is 
frequently felt. The mammary changes continue, with appearance of the 
secondary areola. B allot tement readily reveals the presence of the fetus and 
heart sounds are plainly audible. Sixth month : The sounds and motions of 
pregnancy are all evident. In multigravidae the external os is patulous, ad- 
mitting a finger-tip. The fundus is about at the level of the navel. Cutaneous 
striae develop. Seventh month : The external os may now, even in primiparae, 
admit the finger-tip. The cervix is more elevated in the vagina. The fundus 
is two inches above the umbilicus. Ballottement is still obtainable. The 
vaginal part of the cervix is apparently shortened one-half. Cutaneous striae 
continue to develop. Eighth month : Ballottement is hardly obtainable. The 
fundus is half-way between the umbilicus and ensiform cartilage. The abdomen 
is much enlarged, and is pear-shaped. The umbilicus may begin to pout at the 
end of this month, and in multigravidae milk may be secreted. Fetal parts are 
easily palpable. Ninth month : Ballottement is no longer obtainable, although 
the other physical signs are all more marked. The fundus, at the end of 
this month, is almost at the ensiform cartilage. The cervix still seems shorter. 
The os is very patulous, especially in multigravidae. The umbilicus protrudes. 
Tenth month : The physical signs are distinct. At the middle of this month 
the fundus is at its greatest height. It settles down in the last two weeks, 
thereby lessening the pressure symptoms; while the os also sinks and the um- 
bilical prominence decreases. The patient feels lighter and more comfortable. 
There may, however, be difficulty in locomotion and 'oedema of the genitals 
and legs. The vertex is usually engaged in the pelvis in primigravidae and at 



136 



PHYSIOLOGICAL PREGNANCY. 



the inlet in mult igravi das. The cervical canal in primigravidae shortens and 
disappears just before or at term, and in multigravidas several days or even 
weeks before labor. 



IV. THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 

i. Non-pregnant Enlargements of the Uterus.— (i) Hematometra, usually 
due to retained menses, is a rare condition; non-appearance of menstruation 
occurs with imperforate hymen, or obstruction in the cervical canal, and the 
tumor develops slowly with periodic increase in size (Figs. 174 and 175). (2) 
Hydrometra may be due to the closure of the external or internal os, or both, 
with catarrhal discharge from the mucous membrane, which by its accumulation 
causes enlargement of the uterus. At times a watery fluid accumulates in the 
uterus; this condition is rare, and is very seldom seen before the menopause. 




Fig. 174. — Hematometra. A Non-preg- 
nant Enlargement of the Uterus. — 
{Montgomery.) 




Fig. 175. — Hematocolpometra. A Non- 
pregnant Enlargement of the Uterus. 

— {Montgomery.) 



(3) Physometra is due to the generation and retention of gas in the uterus. This 
is, indeed, a tympanites of the latter. When the uterus has reached such a size 
that it may be percussed, resonance is obtained. Sometimes foul-smelling gas 
escapes per vaginam, and when the uterus is raised its weight does not corre- 
spond with its size, the organ being much lighter than would be supposed from 
its appearance. (4) Pyometra consists in the accumulation of pus in the uterine 
cavity. Hematometra, hydrometra, physometra, and pyometra are very rare 
conditions, while pregnancy is very common. The first three conditions consist 
in the distention of the uterus by blood or other liquid, or by air (gas of some 
sort). The atresia which produces these conditions may be congenital or ac- 
quired. There is no history of exposure to impregnation, as there is in pregnancy ; 
the menses are absent, as a result of imperforate hymen, or of traumatic or inflam- 
matory occlusion of the cervix. In pregnancy there is the normal history of 
menstruation with the sudden cessation of its appearance. In these abnormal 



THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 



13' 



conditions there is a history of a slowly developing tumor, with sudden and 
periodic enlargement, followed by slight decrease in size. These periods cor- 
respond to the menstrual epochs and are characterized by great pain. The 
duration greatly exceeds that of 
pregnancy. By physical examina- 
tion in pregnancy the vagina is 
found congested and softened, while 
in these diseased conditions it is 
generally discovered to be abnormal 
in some respect. The mammary 
changes in pregnancy are sugges- 
tive. (5) Chronic Metritis gives the 
uterus a firmer resistance than is 
imparted by pregnancy; Hegar's 
sign is not present, nor is the char- 
acteristic shape of the " pot-bellied " 
uterus of pregnancy. Amenorrhea 
is often present, and a purulent se- 
cretion frequently coexists. (6) Sub- 
involution is generally accompanied 
by pain in the dorsal or ovarian 
regions, with tenderness of the 
uterus itself. There is a history 
of very abnormal menstruation, 
together with a bloody, muco-puru- 

lent leucorrhea. There is no increase in the size of the uterus, nor are there 
any signs of pregnancy. Locomotion is difficult, and the patient may have 
amenorrhea from anemia or lactation. (7) Myoma and Fibroma: These 
tumors are usually irregular, firm, dense, and not necessarily in the median 




Fig. 176. — Diffuse Interstitial Myomata. 
A Non-pregnant Enlargement of the 
Uterus. — (Montgomery.) 




Fig. 177. — Large Myomata of Anterior and Posterior Uterine Walls. A Non- 
pregnant Enlargement of the Uterus. — (Montgomery.) 



line. Menstruation is irregular and profuse, and the uterine evidences of 
pregnancy are mostly absent, especially the Hegar and Braxton Hicks signs; 



138 



PHYSIOLOGICAL PREGNANCY. 



on the other hand, asymmetry and the uterine souffle are sometimes demon- 
strable. There is, further, a history of slow and protracted growth, which 
may extend over months or even years (Figs. 176, 177, 178, and 179). (8) 
Congestive Hypertrophy of the Uterus: This affection is not infrequently mis- 
taken for pregnancy, especially when accompanied by amenorrhea. However, 
in this condition the uterus is apt to be tender and the seat of considerable 
pain. Time will give the correct diagnosis. 

2. Uterus Normal in Size with Extrauterine Enlargements. — (1) Abdominal 
Fat: This condition becomes more common as age increases. It usually simu- 
lates pregnancy in the very young and anemic. Menstruation in the obese is often 
irregular and scanty. The cervix is neither enlarged nor softened. A uterus 
of normal size may be recognized by 
the vaginal or rectal touch, and if the 
abdominal fat can be pushed aside a 
tympanitic resonance may be obtained 
over the umbilical region. (2) Dis- 
tended Bladder: The duration of this 





Fig. i 78. — Local Interstitial Myo- 
mata. A Non-pregnant Enlarge- 
ment of the Uterus. — (Montgomery.) 



Fig. 179. — Myoma of the Body and Can- 
cer of the Cervix. A Non-pregnant 
Enlargement of the Uterus. — (Mont- 
gomery.) 



condition is relatively brief. There are external discomfort and dribbling of 
urine. The position, shape, and resistance resemble those of the pregnant uterus. 
In retroflexion of the uterus the distended bladder is often mistaken for the 
uterus. Catheterization of the bladder will at once clear up the diagnosis. 
(3) Fecal Accumulation sometimes produces enlargement of the abdomen. 
Catharsis and enemata will remove this condition. (4) Ovarian Tumor (Cys- 
toma) (Fig. 180): In this condition most of the probable signs of pregnancy 
are absent. The abdominal tumor is soft, fluctuating, and usually unilateral. 
A normal uterus should be made out by direct examination. There is also a 
history of a slowly growing unilateral tumor, with the presence of the cachexia 
and facies which accompany ovarian tumors. There may, however, be co- 



THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 139 

existence of the two conditions, which makes the diagnosis difficult. The two 
tumors will then be of different consistence, and may have a groove between 
them. Vaginal examination will reveal enlargement of the uterus, while 
there are also present the signs of ovarian cyst. There should be further evi- 
dences of pregnancy. Aspiration of the ovarian tumor is no longer practised, 
as in this procedure there is nothing to be gained in making the diagnosis, 
(5) Ascites: In this condition the certain and probable signs of pregnancy are 
all absent and the cervix and body of the uterus possess normal characters. 
The abdomen, flattened in front and bulging at the sides, exhibits fluctuation. 
By changing the woman's position the horizontal limits of percussion-reso- 
nance change. In the dorsal position there is dullness in the flanks on percus- 
sion. The condition upon which the ascites depends may be in evidence (cir- 
rhosis of the liver, tuberculous peritonitis, etc.). (6) Pelvic Hematocele : This 
condition, which usually occurs in the broad ligament, could hardly be mistaken 
for pregnancy. (7) Pelvic Exudations: The uterus may be surrounded by 
pelvic exudate, the whole representing an apparently homogeneous swell- 
ing. (8) Retroversion and Retroflexion. These conditions have been mistaken 
for pregnancy at times, 
since they frequently cause 
hypertrophy of the uterus, 
and irregularities or cessa- 
tion of the menses. The 
history must be carefully 
investigated. Vaginal ex- 
amination generally dis- 
closes an anteposed cervix 
of firm consistence. The 
tumor will also be found 
situated in Douglas's cul- 
de-sac. Very careful exami- 
nations, repeated at short 

intervals, will reveal the Fig. 1S0. — Intraligamentous Myoma. Uterus Nor- 
true nature of the case. mal in Size with a Pelvic Tumor.— {Montgomery.) 

Sometimes several months 

will be required to make the diagnosis certain. The greatest difficulty will be 
found in those cases in which the fundus has reached the superior margin of the 
symphysis, or a little higher, before the convincing signs of pregnancy are 
present, and when the fetus is dead. Time is often required for clearing up this 
diagnosis. Large tumors should generally offer little difficulty, but the possi- 
bility of the coexistence of pregnancy and a tumor should always be remem- 
bered. (9) Tympanites : In this condition the whole abdominal surface will 
give a clear note of percussion; the signs of pregnancy, both subjective and 
objective, are all wanting. Tympanites and pregnancy may coexist, however. 
Tympanites may be excluded by feeling the spinal column through the abdomi- 
nal wall. This may be accomplished by firmly pressing the hands, one on the 
other, against the abdomen, while the patient draws deep breaths. The pres- 
sure should be especially firm during expiration. In this way the absence of a 
gravid uterus may be proved. The enlargement also varies in the two condi- 
tions: in pregnancy it is chiefly antero-posterior in the first months, while in 
tympanites it is uniform in all directions. There should be no resonance over 
the uterus, since the intestines, as a rule, are above and behind the organ. As 
before noted, however, the intestines may be forced over the anterior face of 




140 



PHYSIOLOGICAL PREGNANCY. 





the uterus from gaseous distention. (10) Distended Tubes, perhaps adherent 
to the uterus, might possibly simulate pregnancy. In this case they will 
move with the cervix, (n) Encysted Peritonitis and (12) Ectopic Gestation 
may sometimes cause confusion. (13) Enlarged Abdominal Organs may suggest 
pregnancy;- they, however, increase from above downward. In case of wan- 
dering spleen or kidney, the organ can be pushed upward. Resonance may 
be obtained below the limit of dullness and will show the cause of enlargement. 
Encysted dropsy may be met with, but very infrequently. In malignant 
growths of the omentum and mesentery there are irregularity and fixation. 
If the growths are extensive and have existed for some time, there is apt to be 
cachexia. 

3. Pregnancy with Extrauterine Enlargements. — The physician must be on his 

guard against a combination of these 
conditions; for example, intrauterine 
pregnancy and ectopic gestation may 
exist together; or one of these con- 
ditions with an ovarian tumor; also 
in intrauterine pregnancy the uterus, 
from retroflexion, or retroversion, or 
both, may give the appearance of a 
tumor in Douglas's cul-de-sac. Ab- 
dominal enlargement from patho- 
genic conditions sometimes occurs 
in combination with pregnancy. In 
these cases the latter condition is 
very apt to be overlooked, while 
the former is the only one recog- 
nized. In certain cases the patho- 
logical conditions may be removed, 
and then the pregnancy will become 
apparent. The abdominal walls also 
may contain an undue amount of 
fat, which will tend to obscure the 
gestation. (1) Ascites may coexist 
with pregnancy and in various clini- 
cal forms, due respectively to (a) 
tuberculous peritonitis, which may 
develop slowly side by side with 
gestation; (b) some obstruction of 
the portal circulation (cirrhosis of 
the liver, pylephlebitis) ; (c) ob- 
struction of the circulation of lymph ; 
and, finally, (d) pregnancy itself, 
which may produce ascites as a result of a pathological condition which affects 
the maternal peritoneum and fetal amnion. (2) Ectopic pregnancy may be 
associated with normal uterine gestation, and the presence of the latter furnishes 
a contraindication to the operative treatment of the former, although in cases 
of this description both fetuses have been delivered alive by laparotomy. As a 
rule, the embryos have the same degree of development. Normal pregnancy 
may also be associated with a past extrauterine gestation. (3) There may also 
be coexistence of uterine and cornual pregnancy; this latter condition often so 
nearly resembles ectopic gestation that it cannot always be differentiated from 



* 



\. 







Fig. 181. — An Ovarian Cyst Behind and 
to One Side of a Pregnant Uterus. 
Pregnancy with a Pelvic Tumor. — {Mont- 
gomery.) 



THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 



141 



it. (4) Persistent distention of the bladder may sometimes obscure beginning 
pregnancy. It would be almost impossible to confuse the (5) tumor of appen- 
dicitis with beginning gestation. (6) Ovarian tumors not infrequently com- 
plicate pregnancy; this combination may give rise to much danger to the 
mother, for it will be almost impossible for the abdomen to accommodate both 
of these tumors, growing simultaneously (Fig. 181). Sometimes the tumor is 
subjected to such pressure that it may burst and discharge its contents into 
the peritoneal cavity ; or it may give rise to a slow inflammatory process, causing 
much exhaustion, and finally terminating fatally. Several lines of treatment 
are suggested — ovariotomy, or induced labor. (7) At times small tumors 
develop in the lesser pelvis, which may gradually rise above the brim. In this 
case, if the tumor is not behind the uterus, it may be distinguished from that 
organ. On the other hand, the abdomen may be so distended by the presence 
of the gravid uterus and the tumor that hydramnios or twins may be suspected. 
(8) Pyosalpinx or hydrosalpinx may also complicate pregnancy. (9) Other 
tumors of the soft parts 
have at times to be con- 
sidered; e. g., of the broad 
ligaments, tubal and other 
swellings. (10) Ventral her- 
nia and pendulous abdomen 
must be distinguished. (11) 
A large floating kidney, or 
displaced spleen or liver, or 
tumors of any of the abdo- 
minal viscera, such as hy- 
datids of the liver, or carci- 
nomatous tumors, may be 
found in conjunction with 
pregnancy, as has been 
stated. 

In some conditions it is 
possible to remove the trou- 
ble which obscures the preg- 
nancy, and then the latter 
stands out clearly. How- 
ever, the best way of making a true and positive diagnosis of the pregnant 
state is to make several examinations, and to wait until undeniable proofs 
of gestation are present. There is one differential point of great value in 
the diagnosis of pregnancy: after the sixth month it is the only abdominal 
tumor which presents the condition of a movable solid mass in a liquid. 

From a medico-legal standpoint the diagnosis between a multiparous and 
puerperal uterus, and between a primigravida and multigravida, sometimes 
becomes important. Multiparous Uterus: Cavity 2\ inches (6.5 cm.), trian- 
gular; cervix small, cartilaginous, and same length as body; external os trans- 
verse, and edges smooth; uterus anteflexed; external os closed. Puerperal 
Uterus: Cavity 3 inches (7.5 cm.), or over, oval; cervix large, soft, larger than 
body; irregular external os, with roughened edges; axis of uterus straight, 
retrodisplaced ; external os patulous. Primigravida: Fourchette present; peri- 
neum intact; labia in apposition; granular condition of vagina present; cervix 
long, conical, or closed; abdomen tense; pinkish strias, late in pregnancy; breasts 
full, firm, sensitive; nipples undeveloped; strias usually absent from breasts. 




Fig. 182. — Pregnancy Complicated by Myoma of the 
Anterior Uterine Wall. Pregnancy with a Pel- 
vic Tumor. — (Montgomery?) 



142 



PHYSIOLOGICAL PREGNANCY. 



Multigravida: Fourchette absent; perineum relaxed or torn; labia frequently 
patulous; granular condition of vagina absent; cervix short and open; abdomen 
relaxed; white striae, from beginning of pregnancy; breasts relaxed; nipples 
large and developed; striae frequently present on breasts. 



V. FEIGNED PREGNANCY, PSEUDOCYESIS. 

Pregnancy, for various reasons, may be feigned or simulated. Suits are 
frequently brought for damages, or to compel marriage, and it then becomes 
the duty of the physician to render a decision in the case. The pregnancy 
may be purposely feigned or simulated, or the woman in question may really 







Fig. 183. — Author's Case of Feigned or False Pregnancy (Pseudocyesis) at the 
Thirty-sixth Week (?). A bimanual examination revealed a uterus normal in size 
and position.— - {From a tracing.) 



believe herself to be pregnant. The latter condition is one well recognized 
in obstetric medicine; and constitutes what authorities variously term false, 
spurious, or nervous pregnancy, or pseudocyesis. In cases of feigned or simu- 
lated pregnancy, a physical examination removes all doubt; for although the 
woman may simulate many of the doubtful signs of pregnancy in her attempt 
to deceive, yet an examination reveals none of the probable or sure signs, and 
the uterus is found of normal size (Fig. 183). Pseudocyesis is observed in 
women who are advanced in years; in those who have an intense desire to 
become pregnant; in women who marry late in life, and are anxious to prove 
their power of reproduction. Most frequently we observe the condition in a 
woman who is approaching the menopause, when her menstrual flow has become 
scanty, or has ceased outright for a time; a deposit of fat takes place in her 



UNCONSCIOUS PREGNANCY. 143 

anterior abdominal walls, and her intestines become distended by flatulence. 
In such a case many of the doubtful and some of the probable signs of pregnancy 
are present. For example, menstruation may cease; the mammary signs of 
gestation appear, even to the secretion of colostrum or milk; the abdomen 
becomes progressively more prominent; the woman assures her physician that 
fetal movements (quickening) are present; and this may end in what is termed 
spurious labor. (See page 484.) The diagnosis of the condition is not difficult. 
Above all, the physician should be on his guard against accepting any statements 
the patient may offer in regard to her condition; and in expressing an opinion, 
he should rely upon the exclusion of the probable and certain signs of gestation, 
which he does by a careful physical examination of the woman, preferably 
with the aid of anesthesia. 

In the Robert Ray Hamilton case, which occurred in New York in the latter part of 
1888, Mr. Hamilton's mistress represented to him that she was pregnant by him. He be- 
lieved this to be the case, and gave her considerable sums of money to enable her to go into 
the country to be confined. She went away, remained a few months, and upon her return 
produced a child which she stated was the child born at her alleged confinement. He fully 
believed her story and accepted the child as his own. It appears from the police memoranda 
that several children were bought from midwives for sums of from ten to fifteen dollars, and 
that two of these died while acting their parts as supposititious children. Owing to a quar- 
rel between nurses, the fraud was finally discovered, and the woman and her accomplices 
were indicted for obtaining money under false pretenses. The indictment never came to 
trial.* 



VI. UNCONSCIOUS PREGNANCY. 

It is not only possible, but quite common, for women to become pregnant 
and remain so for some time before they become aware of their condition. This 
applies more particularly, if not exclusively, to married females. In the un- 
married, in spite of their serious protestations of entire ignorance of everything 
concerning the matter in question, unconscious impregnation and pregnancy 
is a rare condition. Many cases may be furnished of married women, espe- 
cially those childless for a number of years, who finally really do become preg- 
nant, and then refuse to believe the medical attendant when assured that such 
is the case, believing their altered condition to be due to some disease. "When 
a woman is impregnated in a lethargic state, it is unlikely that she should go 
beyond the sixth month without being fully aware of her pregnancy ; and if her 
motives were innocent, she would undoubtedly make some communication 
to her friends" (Taylor). It must be borne in mind, however, that it is possible 
for a woman to carry her child to full term and be unconscious of the fact of 
pregnancy, t 

* For illustrative cases of feigned pregnancy, see author's article, "Pregnancy, Labor, 
and the Puerperal State," "Medical Jurisprudence, Forensic Medicine," Witthaus and 
Becker, vol. 11, p. 336. 

t Turner, "London Obstet. Trans.," vol. iv, p. 113; also "London Lancet," 1861, i, pp. 
609-643. For illustrative cases of unconscious pregnancy, see author's article on the sub- 
ject in Witthaus and Becker, " Forensic Medicine." vol. 11, pp. 362-364. 



144 PHYSIOLOGICAL PREGNANCY. 



VII. MULTIPLE PREGNANCY; SUPERFETATION. 

Definition. — If more than one ovum becomes impregnated at the same or 
different dates, the result is multiple pregnancy; as twins, triplets, quadruplets, 
quintuplets, sextuplets. Fecundation of an ovum with a double yolk may 
occur. Several cases of six children at a birth have been reported. 

Frequency. — Twins occur once in ninety cases; triplets once in eight thou- 
sand; quadruplets once in four hundred thousand. Multiple pregnancies are 
more frequent in certain countries than others; for example, Bavaria, Ireland, 
and Russia. In 2200 labors I found twins in 31 cases, or once in 70 cases, or 
1.40 per cent. 

Etiology. — The most important factor in the causation of multiple pregnancy 
is heredity, and it shows itself on the maternal side especially. In women who 
have once given birth to twins, an increasing tendency seems to be present for 
multiple pregnancy in subsequent gestations. (1) Multiple pregnancy may 
arise from one or more ova in a single uterus; (2) from two or more ova im- 
pregnated in a double uterus; (3) from one ovum or more in the uterus, and 
one extrauterine. In this connection two analogous conditions, termed super- 
fecundation and superfetation respectively, must be considered. 

Superimpregnation; Superfecundation; Superfetation. — The term 
superimpregnation indicates the impregnation of two or more ova at the same 
coitus; simultaneous fecundation. By the term superfecundation is meant the 
impregnation of one ovule or more after one has been already impregnated; or 
the fertilization of one ovum or more of the same ovulation, at a second coitus, 
after one has been already fecundated — successive instead of simultaneous 
fecundation. The result of superfecundation is simply multiple pregnancy, but 
the children may or may not differ, according as they possess the same father 
or different fathers. By the term superfetation is meant impregnation when an 
embryo already occupies the uterus, or the fertilization of a second ovum after 
the development of the first ovum has been going on in the uterus for a month or 
more. Two results may follow: (1) Two children are born at the same time, but 
different in development; or (2) two children are born at different times, 
equally developed. 

If all of the above conditions are possible, we may have as the result of super- 
fecundation: (1) The birth of twins or triplets, with certain physical pecu- 
liarities, proving that they have had different fathers. And as the result of 
superfetation: (2) The birth of children at the same time, differing in the degree 
of their development; or, (3) after the birth of a mature child, a second one 
equally developed may be born, after the lapse of several weeks or months. 
That superfecundation may occur in both women and the lower animals is now 
a matter of certainty. A mare is covered by a stallion, and after an interval 
of several days, is covered by an ass; the result is twins, — one a horse, the other 
a mule (Mende). A setter bitch during the same ovulation (heat) is covered 
successively by a pointer and a mastiff ; her puppies plainly indicate the different 
fathers. Medical literature supplies abundant cases to illustrate superfecunda- 
tion in woman. 

For superfetation to be possible, the occurrence of ovulation is required 
several weeks or months after the fertilization of the first ovum. The physio- 
logical law in woman is for ovulation to cease as soon as impregnation takes 
place. Nature seemingly intended woman to be uniparous, although we see 
the exceptions in multiple pregnancy. The believers in superfetation lay stress 



MULTIPLE PREGNANCY ; SUPERFETATION. 



145 



been assumed to 




Ch-ulum II 

Ovulum ill 



Fig. 184. — Graafian Follicle with 
Three Ova. — (Von Franque*) 



upon the fact that because women apparently menstruate for one or more periods 
during pregnancy, therefore ovulation occurs at the same time. Playfair cites 
the presence of menstruation as a proof of ovulation. As has been already 
pointed out, the presence of menstruation is no proof that ovulation is also 
present. (See Duration of Pregnancy.) 

Conclusions. — (1) Superfetation has, in many instances, 
exist without sufficient evidence. (2) There 
are on record cases that we are unable to 
explain on any other ground than that of 
superfetation. (3) Whether in all cases of 
apparent superfetation the uterus was nor- 
mal, is not definitely known. The result 
of all the observations made upon this sub- 
ject is, that the majority of the alleged 
cases of superfetation may be explained (1) 
upon the theory of twin pregnancies, in 
which one fetus has grown at the expense 
of the other and is first expelled, the other 
remaining until it has acquired the proper 
maturity; (2) by the existence of a double 
uterus (Fig. 468). Nevertheless there are 
a few other cases which do not admit of 
either of these explanations, and which can- 
not be accounted for except on the theory of 
two successive conceptions (Reese). 

Explanation of Twins. — There are various 
causes for the occurrence of multiple preg- 
nancies. The most frequent is probably the coincident, or almost coincident, 
rupture of simultaneously matured Graafian follicles, whose ova are impreg- 
nated at the same, or very nearly the same, time. As a general rule, twins 
develop from two distinct ova, which are derived from the same or different 

Graafian follicles. They may be situated in different 
ovaries, as proved by the presence and position of 
the corpora lutea. So twins may be derived (a) 
from one ovum from each ovary; (6) from two ova 
from one ovary; (c) from a double ovum, both nuclei 
being fertilized (Fig. 185); (d) from a division which 
takes place in the blastoderm, giving rise usually 
to monsters, but sometimes to twins (Fig. 89). 
The presence of a double nucleus may be assumed 
when twins are derived from a single ovum, but, as 
emphasized by Ahlfeld in his researches on the 
production of double monsters, the possibility must. 
be entertained that the twins may have resulted 
from complete fission of a single germ. The twins are then termed "homo- 
logous," and their mental and physical similarity is striking. Twins origi- 
nating from a single ovum are always of the same sex, while those from two' 
ova may be of the same sex or of different sexes. 

Membranes. — As to the arrangement of the fetal membranes, the decidua 
vera is invariably single ; the decidua reflexa is double when the ova are attached 
* "Zeitschrift f. Geburts. u. Gynakol.," Bd. xxxix. 
t " Zeitschrift f. Geburts. u. Gynakol.," Bd. xxxix. 
10 



it 

9SWT 1 

Fig. 185. — Two Primor- 
dial Follicles in One of 
Which is an Ovum with 
Two Germinal Vesicles. 
— (Von Franque. f) 




146 



PHYSIOLOGICAL PREGNANCY. 



DECIDUA 
SEROTIM, 



ECIDUA 

ER0T1NA 



to parts of the uterine wall widely separated. The chorion, since it takes its 
origin primarily from the zona pellucida, is single when the twins are derived 
from two nuclei within a single ovum, but double when they originate from 

separate ova. Originally the amnion is 
always double, for it is elaborated as an 
outgrowth extending from the embryo 
itself. When twins are in one common 
membrane, there has been, as noted before, 
an absorption of the septum which, for a 
time, served as a barrier (Figs. 187, 188, 
and 189). 

Placenta. — Primarily the placenta is 
double, for each fetus produces its own 
allantois and the placental region result- 
ing therefrom. In the case of twins com- 
ing from different ova, the placenta may 
remain separate, but even in this case 
fusion of the placental areas finally 
occurs. There is almost without excep- 
tion an anastomosis of the vessels of the 
placentae of single-egged twins, conse- 
quently the placentae are fused to a certain 
extent, and there results a common area 
of nutrition for both fetuses; while there 
are two other areas, one for the special use of each fetus (Hyrtl). Hence, if 
there are two distinct ova, there may be expected two sets of membranes, 
while in the case of one ovum with two nuclei, a double amnion but a single 




Fig. 186. — Twin Pregnancy Result- 
ing from Two Ova from the Same 
or Different Graafian Follicles 
and from the same or opposite 
Ovaries. First arrangement of fetal 
structures. A.M., Amnion. The 
heavy black portion indicates the 
chorion. — (Dakin.) 



DECIDUA SEROTINA 



DECIDUA 
SEROTI 



DECIDUA 

SEROTINA 




DECIDUA 

VERA 



DECIDUA 
VERA 



DECIDUA 
REFLEXA 



Fig. 187. — Twin Pregnancy from One 
Ovum with Two Germinal Spots. 
Second arrangement of fetal structures. 
A.M., Amnion. The heavy black por- 
tion indicates the chorion. — (Dakin.) 




DECIDUA 
VERA 



DECIDUA 
VERA 
DECIDUA 
REFLEXA 



Fig. 188. — Twin Pregnancy from One 
Ovum with One Germinal Spot. Third 
arrangement of fetal structures. A.M., 
Amnion. The heavy black portion in- 
dicates the chorion. — (Dakin.) 



chorion, and a single placenta will probably develop. Sometimes only one 
amnion is found, in which case the partition between the two has probably 
been dissolved. Veit found in 429 cases, that 383 were from two distinct ova, 46 
from a single ovum, and two had a single amnion. Ahlfeld found a single 



MULTIPLE PREGNANCY; SUPERFETATION. 147 

amnion in 456 cases, or half as frequently as Veit. In a twin pregnancy with 
one placenta it is very necessary to tie the cord of the infant first born, for 
the second may bleed to death from the cord of the first. 

Abnormal Conditions. — The circulation of one child may be more fully 
developed than that of 'the other, so that the second becomes a monster. There 
may be a marked amount of fluid in one sac and very little in the other (Ahl- 
feld). The anastomoses of the vessels of the placenta may exert a very strong 
influence on the development of the twins. Circulation from the weaker may 
be directed almost entirely to the stronger, and there will result, in the case of 
the first, fetal atrophy, or acardia. In case of the death of one fetus, the living 
child will, in its growth, compress the dead child more and more till it becomes 
a flattened mass pressed against one side of the uterine wall, and known as the 
"fcetus papyraceus"* (Fig. 455). There may be a striking difference between the 
infants at birth, the one being large and vigorous, the other small and puny. 
Now and then it happens that the larger child is born at term, and the immature 
fetus is retained till it has become more like its fellow, when it is likewise expelled. 
Cases of double uteri have been recorded in which two children of the same 
mother have been born a month or more apart (Barker, Generali). 

Explanation of Triplets. — Triplets may be derived from one, two, or three 
ova. A common method is for one child to originate from one ovum, while the 
other two are derived from another single ovum. The arrangement of the 
placentas and membranes will depend upon the method of their origin. 

Explanation of Quadruplets. — Quadruplets may consist of double twins, 
or of triplets together with a single child. 

Symptoms and Diagnosis. — Often there are no subjective symptoms to point 
to this interesting condition. Usually all the symptoms of pressure and con- 
gestion, and sometimes the reflex and sympathetic disturbances, are exag- 
gerated. As a rule, the duration of pregnancy is shortened, by reason of the 
overdistention, by about two weeks. The uncertain signs are: (1) exaggerated 
pressure and congestive symptoms; (2) excessive size and irregularity of the 
uterine tumor, with (3) increased tension of the uterine walls, and (4) diminished 
fetal mobility. The certain signs are: (1) the palpation of similar parts of the 
fetus, as two heads, two breeches, a number of fetal extremities, or after dilatation 
of the os, two bags of membranes. (2) The detection of two or three fetal heart 
sounds at different points of the abdomen, of the same degree or of different 
degrees of intensity, and separated by areas over which the sounds are absent or 
indistinctly heard. Errors in diagnosis are the result of depending too much on 
this sign; in the case of a uterus containing a large fetus, with little liquor amnii, 
and covered by thin maternal abdominal walls, the fetal heart may be heard 
more or less distinctly over the entire uterine surface, and unless two observers 
auscultate and count at the same time, differences in heart rate and intensity 
may appear to be present. I made this mistake early in my private prac- 
tice; the child, a male, weighed o^ pounds. (3) The detection, by bimanual 
palpation, of two fetal poles in the uterus. Thus, with two fingers in the vagina 
upon the presenting fetus, upon pushing this fetal pole upward, the hand upon 
the fundus will perceive an absence of motion in one fetal pole, and the conveyed 
impulse of the vaginal palpation in the other. This, in my experience, is the 
most reliable sign, as I have frequently demonstrated to students in the 
clinic. 

Prognosis. — The dangers for the mother are: (1) greater liability to toxemia 
of pregnancy and eclampsia, on account of the increased metabolism of the 

* See Amorphus anideus, Fig. 399. 



148 PHYSIOLOGICAL PREGNANCY. 

two fetuses, and the greater pressure on the kidneys and ureters. My study 
of 31 cases of twins shows albuminuria almost constantly present. (2) Uterine 
inertia, prolonged labor, and post-partum hemorrhage are liable to occur as a 
result of the extreme uterine distention. (3) Abnormal presentations may be 
present as the result of irregularity in the shape of the uterine cavity. (4) Pre- 
mature expulsion of the fetuses occurs in about 25 per cent., with greater ten- 
dency to placental retention. The fetal prognosis is affected by: (1) Deficient 
development of one or both twins; the stronger and better-developed twin 
attracts more nourishment, and crowds and perhaps kills its fellow {foetus papy- 
raceus); or lack of fetal movement results in poor muscular development of 
the extremities and bodies of both twins. (2) In unioval twins anastomosis 
between fetal and placental vessels is apt to produce monsters. (3) Hydramnios 
is frequent. (4) Complications of malpresentation and position may occur at 
the time of birth. Thus, (a) compound presentations, as double head, double 
breech, and head with breech, or breech with extremities; (b) malpresentations,. 
as shoulder presentation of second child (10 per cent.); (c) coiling and twisting 
of the cords after the onset of labor; (d) locking and welding, an engagement 
and interlocking of both heads, locking of a head or breech with a shoulder 
presentation, interlocking of chins, interlocking of occiputs.* 
Phenomena of Labor. See Part V. 



VIII. THE DURATION OF PREGNANCY. PROTRACTED 

GESTATION. 

Definition. — By the actual duration of pregnancy we understand the time 
that elapses between impregnation and labor. The duration we are unable to 
obtain in any case with exactness, since the date of conception is always un- 
known. The uncertainty is due to two facts: First, there may exist an interval 
of from one to fourteen days between the time of insemination and fertilization 
of the ovum; and, second, it is impossible to know in a given case whether the 
ovum which is fertilized is the product (1) of the last menstrual epoch, (2) of 
the intermenstrual period, (3) of, or the date corresponding with, the first sup- 
pressed period. The real duration of pregnancy, therefore, in the human 
female is an unknown quantity. 

The Average Duration. — We learn from experience that the average apparent 
duration of pregnancy is ten lunar or nine calendar months, or forty weeks, 
or two r hundred and eighty days from the beginning of the last menstrual period, 
or two hundred and seventy-two days from the date of conception. Schlichtingf 
investigated 456 cases, and made the average to be 269.5 days; and yet the time 
varied from two hundred and forty to three hundred and thirty-four days. 
Winckel,{ in his 5010 cases examined, found 70 in which the duration of gestation 
was more than three hundred days, and in 6.8 per cent, of those cases in which 
the exact date of impregnation was considered known, the duration was more 
than three hundred days; in one case the duration was three hundred and 

* In 3 1 twin labors in hospital practice I found the maternal mortality o per cent. 
Both children lived in 24 cases, or 77.41 per cent., and one lived and one was still-born in 
6, or 19.35 P er cent. Labor was natural in 20 cases, or 64.51 per cent.; the forceps was re- 
quired in 4 instances (once in eight cases) ; version in 4 and breech extraction in 1. 

t "Arch. f. Gynak.," Bd. xvi, 210. 

t "Text-book of Midwifery," 1890, p. 94. 



DURATION OF PREGNANCY ; PROTRACTED GESTATION. 149 

fourteen, and in another three hundred and eighteen days. Lowenhardt,* 
from 518 cases in which the women could give the date of the fruitful coitus, 
found that the average duration of pregnancy from the date of conception was 
272.2 days. Leuckardt, in an analysis of 67 cases found upon the marriage 
and birth register of a church, in which labor occurred within ten months after 
the marriage night, computed the average duration of pregnancy to be 272.5 
days. Hasler,f from a large number of cases in which the date of the impreg- 
nating coitus was known, estimated the average duration of pregnancy to be 
272.24 days from the date of conception, and 280.5 days from the beginning of 
the last menstrual epoch. Issmerj in an exhaustive paper upon the duration 
of pregnancy, based on a careful analysis of 464 cases, has given the following 
interesting conclusions: (1) Conceptions occurring in the first half of the inter- 
menstrual period are to those in the second half as 72 to 27. (2) Pregnancies 
dated from the first half of the intermenstrual period are shorter in duration 
than those dated from the second half. (3) When impregnation occurs in the 
first half, the ovum fertilized is that which was discharged at the last men- 
struation (ovulation); while when it occurs in the second half, the ovum im- 
pregnated is one that escapes at or near the next menstrual period. (4) The 
average duration of pregnancy is two hundred and sixty-eight days from con- 
jeption, or two hundred and seventy-eight days from the completion of the last 
menstruation. Maximum duration, three hundred and four days. 

Authorities differ somewhat in giving the average duration of gestation in the human 
subject. Thus (calculated from the first day of the last menstruation) : Schlichting § (440 
cases) gives 273.1 days; Matthew Duncan || gives 278 days; Lowenhardt-Ahlfeld ^ (166 
cases) gives 281.6 days; Hasler (large number) , 280.5 days. And, calculating from concep- 
tion, Schlichting,** 456 cases, gives 269.5 days; Lowenhardt, ft 518 cases, gives 272.5 days; 
Leuckardt, JJ 67 cases, gives 272.5 days; Hasler, §§ large number, gives 272.24 days. 

Protracted Gestation. — A case is reported by Thomson |||| in which gestation lasted 317 
days from the last menstrual period, or 301 from the last sexual intercourse. Kruche^ffl re- 
ported a case in which he believed the duration of pregnancy was 330 days. The latest period 
to which pregnancy may be protracted is stated by various authors as follows: Depaul, 300 
days (high limit) ; Robert Barnes, 300 days (improbable) ; Issmer,*** 304 days, Winckel,ttt 
320 days; Schroder, %%X 320 days; Schlichting, §§§ 334 days; Runge,|||||| 320 days. 

Reese tUl states that it is possible for pregnancy to be prolonged beyond the usual 
period accepted as the average, but he gives no limit. 

As to the legitimacy of offspring according to the duration of pregnancy, different coun- 
tries possess different laws. In Austria **** the law recognizes the legitimacy of the child 
born within 240 to 307 days after the death of the father. In France fttt "the legitimacy 
of the infant born 300 days after the dissolution of the marriage is liable to be contested." 
In England and America "the light of the courts in this matter is reflected light. Physicians 
must determine the matter; and if the space between the minimum and maximum periods 
hitherto allowed is shown to be too long or too short, the courts will readily follow the truth 
as it is made manifest." In Wharton "On Evidence" (sec. 1, 300) we find no absolute 
limit laid down. Each case is determined upon its merits. A liberal view is taken, and the 

* "Arch. f. Gynak.," in, 1782. 

t "Ueber die Dauer der Schwangerschaft," Ztirich, 1876. 

X "Arch. f. Gynak.," xxxv, 1889, p. 310. § "Arch. f. Gynak.," Bd. xvi, 210. 

|| Ibid., Bd. in, 456. V'Monat. f - Geburtsh.," xxxiv, 180, S. 266. 

** Loc. cit. ft Loc. cit. JJ Loc .cit. §§ Loc. cit. 

Illl "Trans. London Obstet. Soc," vol. xxvu. 
TfT[ "Deutsche med. Zeitung," von Grosser, 1883, 370. 
*** "Arch. f. Gynak.," Bd. xvi, 210. 
ttt "Text-book of Midwifery," 1890, p. 94. 
tXX "Lehrb. der Geburtsh.," 9te. Aufl., Bonn, 1886, p. 109. 
§§§ "Arch., f. Gynak.," Bd. xvi, 210. 
Illlll "Lehrb. d. Geburtshiilfe," Berlin, 1891. 
ITU "Text-book of Med. Jur. and Tox.," Phila., 1889. 

**** "Das k. k. Oesterreichische burgerliche Gesetzbuch," "Amer. Sys. Obstet.," vol. 1. 
tttt L'article 315 du code civil. 



150 PHYSIOLOGICAL PREGNANCY. 

legitimacy of births at the completion of 313 and 317 days respectively has been judicially 
decided. This limit of 317 days is, according to most medical authorities on the subject, an 
extreme one. 



IX. CALCULATING THE DATE OF CONFINEMENT. 

1. When the Date of a Single Cohabitation is Known. — Add 280 days, or 
(Naegele's rule) count back three months from the date of cohabitation, and add 
seven days for impregnation. In leap years, after February 6th, the number of 
days to be added varies according to the month; e. g., in February, four days; 
in December and January, five days; in April and September, six days. 

2. When the Date of the Last Menstruation is Depended Upon. — (1) Count 
back three months from the appearance of the last menstruation, and add ten 
days, three for menstruation and seven for impregnation. The first day of the 
last menstruation is a date far more readily obtained than the date of cessation, 
and is the best time to count from. (2) Duncan's rule: Add to the last day 
of the last menstruation, nine months, which should be counted as 275 days, 
unless February be one of the months, in which case the period will be 273 days. 
To the date thus obtained, add three days in the former case, and five in the 
latter, which will make 278 days. This two hundred and seventy-eighth day 
will be the middle of the fortnight in which labor will be apt to take place. (3) 
Lowenhardf s method: Reckoning is made of the number of days between the 
last menstrual epoch and the one preceding that. This result, multiplied by 
10, will represent ten menstrual periods, and will be very accurate. 

3. When the Date of the Last Menstruation is Unknown. — If a woman becomes 
pregnant when she is not menstruating, — in lactation, for example, — or when 
from any other reason the date of the last menstruation cannot be ascertained, 
some method must be employed which does not take this into account ; such as 
(1) counting from the date of quickening; (2) mensuration of the fetus in 
utero; (3) height of the fundus; (4) time of lightening; (5) changes in the cervix. 
(1) From date of quickening: Count from the first appearance of the "quick- 
ening," which, on the average, appears at the seventeenth week. To this date 
is added four and one-half months, in order to estimate roughly the date of 
confinement. (2) From the height of the fundus an approximate idea may be 
obtained; fourth month, the fundus occupies the hypogastrium; fifth month, 
midway between symphysis and umbilicus; sixth month, on a level with the 
umbilicus or just above; seventh month, midway between the umbilicus and 
xiphoid cartilage; eighth month, at xiphoid cartilage; ninth month, descends 
almost to depth at which it was in seventh month, the presenting part having 
entered the pelvic brim in primigravidae. On account of the variations in the 
position of the umbilicus, Spiegelberg estimated the height of the fundus above 
the symphysis in the different weeks of pregnancy. His results are appended: 

From 22d to 26th week fundus of uterus 8.56 inches (20.0 cm.) above symphysis. 
At the 28th 

" 30th 

" 32d-33d 

" 34th 

" 35th-36th 

" 3 7 th- 3 8th 

" 39th— 40th " 

(3) By measurement of the fetal ellipse: On account of the variations in individual 
pelves, and the importance in contracted pelves of the size of the fetus, Ahlfeld 
has paid much attention to the measurement of the child in utero. The fetal 
ellipse in the last months of pregnancy is nearly half the length of the fetus ; 
*. e., the length of the long axis of the fetus, as it lies flexed in the uterus, is about 



10.43 


(25.0 cm.) 


11.02 ' 


(27.5 cm.) 


II. 81 


(29.0 cm.) 


12.00 ' 


(30.0 cm.) 


12.50 


(31.5 cm.) 


12.99 ' 


(33.0 cm.) 


13-39 


(34.5 cm.) 



CALCULATING THE DATE OF CONFINEMENT. 



151 



half the length of the extended fetus (Fig. 189). These measurements are taken 
by means of calipers, one end of which is rested against the presenting part in 
the vagina, and the other against that part of the fetus in the fundus of the 
uterus. Thus, whenever admeasurement is taken of the fetal ellipse, it will 
represent half the length of the fetus at that particular date. The table be- 
low gives the correspond- 
ing length of the fetal 
ellipse, of the extended 
fetus, and its weight at va- 
rious weeks of its growth : 
This method is used when 
the fetus presents longitu- 
dinally. When the pres- 
entation is transverse, the 
measurement is purely ab- 
dominal. (4) The phe- 
nomenon of lightening at 
the beginning of the pre- 
paratory stage to labor, al- 
though its value in fore- 
telling the day of delivery 
is not great. (5) Changes 
in the portio vaginalis and 
cervical canal in the latter 
part of pregnancy, es- 
pecially in primigravidae, 
should be taken into con- 
sideration. 





Fig. 189. — Calculating the Date of the Expected 
Confinement by Measuring the Fetal Ovoid with 
One Point of the Pelvimeter on the Fetal Head 
in the Vagina, and the Other on the Breech 
through the anterior abdominal wall. 



Period of Preg- 
nancy. 


Axis of Fetal Ellipse. 


Total Length of Fetus. 


Weight of Fetus. 


At the 20th week 


3.82 to 5.79 in. (9.7 to 
14.7 cm.) 


7.08 to 10.62 in. 
to 27 cm.) 


(18 


9.8 oz. (280 grams) 


24th " 


5.90 to 7.36 in. (15.0 to 
18.7 cm.) 


11.02 to 13.48 in. 
to 34 cm.) 


(28 


1.395 Ihs. (634 grams) 


28th " 


7.08 to 8.97 in. (18.0 to 
22.8 cm.) 


13.88 to 14.96 in. 

to 38 cm.) 


(35 


2.64 lbs. (1200 grams) 


32d 


9.45 to 10.82 in. (24.0 to 


14.96 to 16.93 i n - 


(38 


3.52 to 4.18 lbs. (1600 




27.5 cm.) 


to 43 cm.) 




to 1900 grams) 


36th " 


10.63 to 11. 81 in. (27.0 


16.52 to 18.90 in. 


(42 


3.74 to 5.72 lbs. (1700 




to 30.9 cm.) 


to 48 cm.) 




to 2600 grams) 


40th " 


11. 81 to 14.56 in. (30.0 


18.90 to 20.47 ' m - 


(48 


6.60 to 7.92 lbs. (3000 




to 37.0 cm.) 


to 52 cm.) 




to 3600 grams) 



The exact day of delivery probably depends on small details, either mental 
or physical. Impregnation has been observed to occur at any time in the men- 
strual month, although considered to take place more frequently in the few 
days just preceding, and those immediately following, menstruation. Some 
women always seem to exceed the normal limits of pregnancy, and in such cases 
the child is usually a large-sized male. In other cases the duration of pregnancy 
is shorter than usual; it is said to be so, early and late in the reproductive age, 
and in single women, while it is long in the middle part of the child-bearing 
period. It is quite likely that the gestation period corresponds with the length 
of the individual's menstrual cycle. If fecundation takes place a few days 
after the close of a menstrual period, the next menstrual period is almost 



152 PHYSIOLOGICAL PREGNANCY. 

invariably suppressed. If, however, it occurs a few days before a menstrual 
epoch, then there may be an irregular or atypical menstruation succeeding. 
In the case of a woman with an irregular menstrual history the difficulties of 
calculation increase. 



X. THE EXAMINATION OF PREGNANCY. 

Xo better time than that of the examination of pregnancy can be selected 
for inculcating in the student the principles of obstetrical cleanliness, mechanical 
and chemical. The principles of personal cleanliness and disinfection, if not 
learned now, are less likely to be acquired hereafter. While it cannot be stated 
that the same danger attends vaginal examinations in pregnancy as in labor, 
still, in the latter part of pregnancy, the examining finger often enters the cer- 
vical canal, and in the one or more weeks of the preparatory stage of labor the 
conditions are often quite analogous to active labor. Moreover, the possibility 
of a low placental attachment, or even of actual labor, must always be granted. 
For these reasons obstetric asepsis demands that the same rigid cleansing of the 
hands and forearms, and precautions in separation of the sides of vulva, be ap- 
plied to the examination of pregnancy, as to that of labor and the puerperium. 

Obstetric Asepsis. — In Vienna, in 1847, the foundation of aseptic midwifery 
was laid by Semmelweis, and perfected by others along the lines laid down 
by Pasteur and Lister. Semmelweis, in 1847, discovered the septic nature of 
puerperal fever, and by means of chlorine solutions instituted an antiseptic pro- 
phylaxis against the scourge. In brief, puerperal fever was, according to Sem- 
melweis, no new specific disease, but a variety of pyemia. With this origin 
in 1847, antiseptic midwifery grew and developed, until it reduced the mortality 
of septic infection from 10 per cent, to a fraction of 1 per cent.; until it prac- 
tically did away with so-called epidemics of puerperal fever, and, with the prin- 
ciple of antisepsis properly applied, robbed child-bearing of its greatest danger. 

At the beginning of the present century the consensus of opinion was that 
the pregnant vagina and gravid and puerperal uterine cavity were quite sterile 
under normal conditions, and that autoinfection from these sources was quite 
impossible except in rare instances. In other words, septicemia was in the 
vast majority of cases a disease introduced from without. The evidence upon 
which this view rested, including the result of the labors of Bumm, Kronig, 
and others, was thought to be irrefutable. Of course, theories were not wanting 
to explain this supposed sterility of the birth-tract, and the chief of them had 
reference to the bactericidal power of the vaginal secretion and lochia,* each 
of which was pronounced to be not only a poor culture-medium, but, moreover, 
endowed with powers of self -purification, even after the introduction of an 
abundance of germ-life. Occasional failure of the protective power in these . 
fluids was set down to pathological alterations, or to greatly lowered resistance 
of the organism as a whole. But even had the vaginal secretions possessed 
none of this defensive power, it was still thought impossible for germs to migrate 
rapidly and commonly from the lower part of the vagina to the upper part 
and to the uterine cavity. This theory was in excellent accord with practice, 
for it inculcated the greatest thoroughness in obstetric asepsis and made 
the practitioner practically responsible for the occurrence of an aseptic puer- 
perium. From this point of view I trust the profession will never recede, but 
as a matter of fact the views thus held as a scientific gospel have within the 

* As will be seen later, the lochia does possess such powers, although they are hardly in 
force directly after delivery. 



THE EXAMINATION OF PREGNANCY. 153 

past few years been completely undermined by new discoveries. An increasing 
number of observers have found that the healthy vagina of the pregnant woman 
is by no means always sterile; and that streptococci pathogenic to animals 
may be recovered from not a small proportion of cases. Two of the most 
recent authorities, von Rosthorn * and Lenhartz,y accept the view that the 
vagina is not sterile, and possesses no inherent bactericidal power. At the 
same time, Franz,! Schauenstein,§ AVormser, || and others have shown that 
ordinary saprophytes and streptococci invade the uterine cavity immediately 
after labor in a very large number of cases. TValthard r claims that vaginal 
germs at times readily pass into the non-pregnant uterus, where they may set 
up endometritis and toxemia. The locomotive powers of virulent streptococci 
in cultures is of course well known; for example, according to Bumm,** these 
germs, after having inoculated birth-traumas in the vulval region, can migrate 
into and infect the endometrium in twenty-four hours, while the rapid decom- 
position of retained decidual and placental structures shows that saprophytes, 
whatever their source, have ready access to the puerperal uterus. Sepsis of 
grave character occurs not rarely in women who have never been submitted 
to the examination of pregnancy and in those who have been examined with 
sterilized gloves. 

According to the older views, the external genitals alone abounded in germ 
life, and much of the puerperal morbidity could be attributed to the accidental 
transportation of these germs into the vagina by the examining finger, and by 
manipulation on the part of the patient. 

I found that the secretion in the vulval canal, in twenty-eight pregnant 
and two parturient women in the Emergency and Maternity Hospitals, showed 
pyogenic bacteria in forty per cent, of the cases: Staphylococcus pyogenes 
albus in 8 cases, Staphylococcus pyogenes aureus in 3 cases (both in one patient), 
and Streptococcus pyogenes in one case. In all but two of the cases the ex- 
ternal genitals were washed with soap and water just previous to the taking of 
the cultures. ft 

Vaginal Examinations and Manipulations. — We may accept the following 
statement as probable: The microbes which are known to cause puerperal 
morbidity may or may not be present in the healthy vagina. From the very 
large proportion of cases in which they invade the uterus immediately after 
labor the chances are that the majority of vaginas contain germs. These, 
while comprising even Streptococcus pyogenes in a goodly proportion of cases, 
must not straightway be regarded as pathogenic; they may or may not be 
so. The question must arise, "If we believe that the vagina in a very large 
proportion of cases contains germs which are almost certain to pass into the 
uterus after delivery, and which while not necessarily or ordinarily pathogenic 
may still be the cause of severe and even fatal sepsis under certain circum- 
stances, should we return to the old custom of antiseptic douching of the vagina 
as a routine practice?" At present this question, it must be confessed, is by 
no means easy to answer offhand. Such antisepsis is still practised as a pro- 
cedure of necessity in selected cases, as in suspected gonorrhea, before manual 
or operative delivery, etc. (See Part X.) TVe have no means of differentiating 

* von Winkel: " Handbuch d. Geburtshulf e , " Bd. 1, 1903. 

f " Die septische Erkrankungen," 1903. 

t Franz: " Hegar's Beitrage z. Geburtshulf e , " 1002, vi. § Cited by Franz, v. supra. 

|| Ibid. ^[Walthard: " Zeitschr. f. Gebiirts. u. Gyn., 1902, xlvii. 

** " Grundriss zum Studium des Geburtshulf e," 1902, p. 655. 

ft See author's experiments on 13 primigravidas and 17 multigravidae at Emergency and 
New York Maternity Hospitals. "Asepsis in Obstetrics," " New York Medical Record," 
Feb. 11, 1S99, vol. lv, p. 193. 



154 PHYSIOLOGICAL PREGNANCY. 

between sterile and non-sterile vaginal secretions, for Doderlein's distinction 
between normal and pathological secretions — the latter having an alkaline 
reaction and excess of formed elements — has little practical value. We know 
in advance that the majority of cases in the absence of vaginal antisepsis will go 
through the puerperium without morbidity. We may also feel fairly positive 
that a certain proportion of women will in the long run undergo more or less 
severe sepsis, with secondary morbidity, and perhaps some fatalities. But 
should douching really reduce morbidity? When vaginal antisepsis was prac- 
tised as a routine procedure, it was asserted that the upper vagina could not 
be rendered sterile. I can at present see but one way in which this question 
can be answered. If some of the experimenters who have developed the tech- 
nique for obtaining the lochial secretion from the puerperal uterus will submit 
a large series of cases to antiseptic vaginal douching before delivery, and will 
then investigate the bacteriology of the uterine cavity on the various puerperal 
days, we might gather some notion of the efficacy of vaginal antisepsis. 

Another method of some value might be the taking of rectal temperature, 
as is Bumm's * custom, with a view of detecting febriculae from slight saprsemia, 
the woman having previously been submitted to vaginal antisepsis. If the 
thirty per cent, to sixty per cent, of elevation of temperature (100.4 F. in 
the rectum) should show a marked reduction, we might well conclude that 
vaginal douching should be practised. 

Hofmeier (Wurzburg) j has repeatedly asserted the value of routine prophy- 
lactic antepartum douching, and credit must certainly be given him for securing 
the smallest morbidity and mortality of any maternity in Germany. This 
obstetrician has had but four deaths in his last 6000 deliveries — a mortality 
of but 0.06 per cent. It should be added that the general hygienic conditions 
at Hofmeier 's clinic are by no means favorable, and that his cases are examined 
by a very large number of students, candidates for state examinations and 
by mid wives. Sublimate is used as an antiseptic. 

Lenhartz J states that of forty deaths from puerperal infection at the Eppen- 
dorfer Krankenhaus, Hamburg, no less than twenty-two occurred after normal 
spontaneous labor. It seems a reasonable supposition that antepartum douch- 
ing would have saved many of these women. Lenhartz recommends prophy- 
lactic douching with sublimate (1 : 4000) or lysol (two per cent.). 

Preparation of the Patient. — While it is not often feasible to prepare a patient 
in pregnancy for vaginal examination, as is done at the time of labor, still the 
bladder and rectum should have been emptied, the external genitals scrubbed 
with soap and water with a soft brush or cotton, the whole, including the vulval 
canal, rinsed with plain water, and then cleansed or irrigated with 1 : 2000 or 
1 : 4000 sublimate solution, from above downward. 

Preparation of Physician. — Care of the Finger-nails. — The proper care 
of the surgeon's nails is not a matter of scraping, gouging, and snipping, 
but of gentle training and grooming, following one or two simple principles. 
The old method of cutting the cuticle — thus causing abrasions, sensitive spots, 
rough surfaces, and edges — has given place to quite another simple and 
efficient method, which requires only the efforts of one who is painstaking in 
everything to keep the finger-nails clean and readily asepticable (Fig. 190). 
Ragged, unclean, badly groomed finger-nails are inexcusable in the obstetri- 
cian, and certainly predispose to sepsis, since they cannot be readily rendered 
aseptic (Fig. 190). With a few minutes' attention each morning, one can keep 

*Bumm: " Zeitschr. f. Medizinal-beamte," April 1, 1903. 
t Hofmeier: " Munch, med. Wochen.," 1902, Nos. iS, 19. 
t Lenhartz: " Die septisch. Erkrankungen," Wien, 1903. 



THE EXAMINATION OF PREGNANCY. 



155 



his finger-nails in good condition. Until the nails and cuticle are gotten into 
proper condition, it is a good plan to 
rub a little white vaseline into the 
cuticle every night, and push it back 
with a soft towel or blunt-pointed 
instrument, immediately after washing 
the hands in the morning. All that is 
necessary to keep the nails in good 
condition is (i) a good pair of curved 
pointed scissors; (2) a thin, flat, delicate 
nail-file; (3) an orange-stick, or wooden 
meat-skewer; (4) a nail polisher. A 
clean rough towel will answer for a pol- 
isher. The shape of the nail is largely 
a matter of individual taste, but for 
aseptic purposes a nail with rounded 
point will best serve the obstetrician's 
purpose, provided that at the rounded 
point the nail is not more than -^ inch 




(0.15 cm.) in length. The physician 
should use the scissors and nail-file twice 
a week to bring the nails to the proper 
length and shape ; the file only when the nails are dry. 
always from the sides inward toward the center 
of the nail. The file should be held just under the 
edge of the nail, so that the shreddy lining will be 
removed. Cutting the nails too frequently makes 
them brittle and liable to fractures and crevices, 
and hence the file is preferable for shortening and 
shaping. If the file is used every day, or every 
second day, — as it should be, — trimming with the 



Fig. 190. — The Left-hand Finger shows 
an Exaggeration of a Badly Groomed 
Finger-nail andCuticle which Would 
Favor Sepsis from the Lodgment of 
Septic Material. The Right-hand 
Finger shows a Properly Kept Nail 
and Cuticle. 



Filing should be done 




L 



Fig. 191. — Flattened End of an Orange Stick 
Used to Push Back the Cuticle from the Nail. 



Fig. 192. — Orange Stick with 
Blunt and Flattened Ends 
for Care of the Finger- 
nails. 



156 



PHYSIOLOGICAL PREGNANCY. 




V 



scissors will be unnecessary. The more brittle the nails, the more frequently 
should the file be used, to the exclusion of the scissors. When the filing is 
completed, the finger-tips should be washed and soaked in warm water and 
soap. With an orange stick or meat-skewer, fashioned at the end in the 
form of a blunt chisel, the cuticle should be gently pushed back, so that 
the small half-moons are brought into view at the base (Fig. 191). The 
less the cuticle is cut with knife or scissors, the smoother and healthier it 
■can be kept, and the more readily rendered ase.ptic. With the same skewer 
or orange stick the accumulations under the nail are removed, always using 
or this purpose a wooden or smooth bone or ivory instrument, or the 
edge of a towel (Fig. 193); never anything that will scratch or abrade the 

under surface of the nail, and thus 
milita'te against subsequent asep- 
sis. Should the under surface 
be stained from the previous use 
of permanganate of potash solu- 
tion, or from other cause, it can 
be bleached by dipping the blunt 
stick into lemon juice, a strong so- 
lution of chloride of lime, or oxalic 
acid, and passing it backward and 
forward under the nail. Hang- 
nails and dead cuticle at the cor- 
ners of the nails should be removed 
with the fine curved scissors. 
Finger-nails properly cared for are 
not necessarily highly polished. 
After attending to the cuticle and 
under surfaces, the outer surface 
should be polished upon a dry 
towel, one end of which is held by 
the teeth or doubled over a hook, 
and the other held with the disen- 
gaged hand (Fig. 193). Polishing 
should always be from the sides 
up toward the center of the nail, 
and one nail should be treated at 
a time. For rough or fissured 
nails a chamois polisher and nail- 
polishing powder should be used 
to secure a uniform smooth sur- 
face, in order to lessen the dangers of lodgment of septic material. 

Disinfection of the Hands. — The foundation of the aseptic method in 
obstetrics rests upon sterilization of the hands, which may be accomplished 
in one of several ways. It must be remembered that when we refer to the hand 
we include as well the forearm to the elbow, which in all cases, especially in 
labor and operative obstetrics, should receive the same conscientious cleansing 
as the hand and fingers. To this end the coat should be removed and the sleeves 
rolled up before the cleansing process begins. Women physicians should have 
the sleeves of both arms so made as readily to permit of being rolled back to 
the elbow. All methods of disinfection should be preceded by thorough and 



Fig. 193. — Edge of a Towel Used for 
Cleaning and Polishing the Inner Sur- 
face of the Finger-nail. 



THE EXAMINATION OF PREGNANCY, 



157 




Fig. 



194. — Hand Enclosed in Rubber 
Glove. — {From a photograph.) 



prolonged scrubbing with a hand-brush in soap and hot water, particular atten- 
tion being given to the spaces under and around the nails, which are to be 
kept short and smooth. (See Care of the Finger-nails.) About five minutes 
should be employed in the scrubbing process, which is to be followed by some 
form of chemical antiseptic treatment. ' 

Rubber Gloves. — I cannot too strongly urge the use of sterile rubber 
gloves, as a routine measure in confinement cases. No ordinary obstetrician, 
namely, the so-called general practitioner, and no physician, surgeon or 
obstetrician, who is at all doubtful 
concerning his personal asepsis, is 
justified in attending women in con- 
finement without utilizing this simple 
and effective precaution. 

Chemical Antiseptics. — The 
most generally employed chemical 
antiseptics are carbolic acid and bi- 
chloride or biniodide of mercury. A 
very large number of other chemicals 
have been suggested and used more or 

less, but few of them have any qualities which will enable them to displace the 
substances first mentioned. Among those which have from time to time proved 
useful may be enumerated permanganate of potash, oxalic acid, chlorinated lime 
and carbonate of soda, alcohol, creolin, lysol, and hydrogen peroxide. Creolin 
is not often used at present, but lysol, in a two per cent, solution, is employed 
to some extent as a vaginal douche before labor, when there is reason to believe 
that there is infection present in the vagina, and also as a solution for instru- 
ments. It is objectionable for the latter use because it makes the instruments 

slippery, while this lubricating 
quality is somewhat useful when 
employed in the vagina. Bi- 
chloride of mercury is used in 
solution for various purposes in 
strengths of 1 : 500 to 1 : 10,000, 
and the same is true of the bin- 
iodide. The tablets which are 
extensively sold are very con- 
venient and accurate in making 
solutions of these chemicals, and 
they have the additional advan- 
tage that substances are com- 
bined with them which prevent 
the solutions becoming inert as 
a result of the affinity of the 
mercuric salt for albuminous bodies. Carbolic acid is used in watery solutions, 
to which a little glycerin has been added. The strengths vary from 1 : 20 to 
1 : 100. After the preliminary scrubbing one of the following antiseptic 
methods should be employed: 

1. The scrubbed hands and forearms are (1) rinsed in sterile water; (2) 
immersed for half a minute in alcohol of at least 80 per cent, strength; and 
(3) then in a 1 : 1000 or 1 : 2000 solution of bichloride or biniodide of mer- 
cury, for from three to five minutes. A scrubbing-brush may also be used 




^ORIDE^LIME 



S. 






Fig. 195. — Commercial Carbonate of Soda and 
Chloride of Lime for Use in Rendering the 
Hands and Forearms Aseptic. — {From a photo- 
graph.) 



158 



PHYSIOLOGICAL PREGNANCY, 



with advantage in these solutions, to assist in causing the antiseptic to pene- 
trate. 

2. After scrubbing, the hands and forearms are (i) immersed in a saturated 
solution of potassium permanganate until they are stained a deep mahogany 
brown; (2) they are then transferred to a saturated solution of oxalic acid, and 
kept immersed until decolorized. (3) After this they are rinsed in sterile water 
or salt solution. This method is very efficient. Some writers advise washing 
for three minutes in a 1 : 500 bichloride of mercury solution, as an additional 
precaution after the oxalic acid is washed off (Halsted, 1899). 





Fig. 196. — Opened Vulva in a Primi- 
gravida, Aged Twenty-two; Thirtieth 
Week of Pregnancy; Deep Vulval 
Canal. — (From a photograph at the New 
York Maternity.) 



Fig. 197. — Opened Vulva in a Multi- 
gravida, Aged Thirty-five; Thirty- 
eighth Week of Pregnancy; Moder- 
ate Depth of the Vulval Canal; 
Atrophy of the Caruncul^s Myrti- 
formes, and absence of the four- 
chette. — (From a photograph at the New 
York Maternity.) 



3. (1) A paste is made by mixing water with chlorinated lime ; the hands are 
rubbed thoroughly with this, and (2) meanwhile a lump of sodium carbonate 
is picked up and rubbed in with the mixture, until a sensation of coolness is felt. 

(3) A hand-brush may now be used with the solution for several minutes, and 

(4) the hands washed in sterile water and then in (5) alcohol or weak ammonia 
water. The last two methods are very efficient and are commonly used by 
surgeons in operating, but even after these precautions cultures from the deeper 
layers of the skin will sometimes grow. After the sterilization of the hands is 
complete, the obstetrician must see to it that his hands are not again contami- 



THE EXAMINATION OF PREGNANCY. 



159 



nated by coming in contact with anything which has not been sterilized, between 
the antiseptic solution and the vagina. 

Sterilized rubber gloves will be found useful in obstetrical practice for making 
examinations, especially when the hands have recently had to do with septic 
cases, or when the means for a chemical sterilization are not at hand. The 
rubber gloves can be sterilized by boiling' (Fig. 194). If a lubricant is necessary, 
and it rarely is, it should be vaseline or glycerin which has been heated for 
five or ten minutes to 212 F. and kept afterward in a sterilized vessel. 

Objects of the Examination. — In the examination of pregnancy (1) the actual 
existence of pregnancy should be determined, as well as (2) the period of gesta- 
tion; (3) the probable date of 
labor; (4) the viability of the 
fetus; (5) the diagnosis of the 
presentation, position, and en- 
gagement of the head; (6) the 
condition of the patient's genital 
organs, including the breasts; (7) 
the size of her pelvis; and (8) 
the obstetric prognosis. It is 
advisable also at this time to in- 
quire and record (see chart, Appen- 
dix) (1) the date and type of the 
last menstruation; (2) her family 
and personal history, including 
degree of parity; (3) the char- 
acter of her previous pregnancies, 
labors, and puerperiums. Her 
nurse or nurses should also be 
arranged for, and directions given 
regarding the hygiene of preg- 
nancy and the procuring of the 
mother's, baby's, and obstetric 
outfit. (See Part IV.) Primi- 
gravidas should have their pelves 
measured before the twenty- 
eighth week; the spines, crests, 
trochanters, external and internal 
conjugates, being measured as 
matters of routine. Should pel- 
vic deformity exist, more ex- 
haustive measurements should be 
taken, and if necessary we should 
not hesitate to make an internal examination under nitrous oxide, chloro- 
form, or ether. A comparison should be made between these measurements 
and the weight and height of the patient, and her husband, and their ages. 
The patient's skeleton should be considered as to its character; one composed 
of light bones has generally a relatively large pelvic girth, while the converse 
also holds true. If the patient be a multigravida, all of these careful measure- 
ments are not necessary in private practice, if the previous children have been 
of usual size and the labors uneventful. However, the size of the fetal head 
should be estimated two weeks before labor is expected, in order to detect any 
overgrowth of the fetus. (See Cephalometry.) The examination of pregnancy 




Fig. 198. — Opened Vulva in a Primi- 
gravida; Thirty-eighth Week; Shallow 
Vulval Canal. — (From a photograph at the 
New York Maternity.) 



160 



PHYSIOLOGICAL PREGNANCY. 



can conveniently be divided into (i) external or abdominal, and (2) internal or 
vaginal. 

EXTERNAL OR ABDOMINAL EXAMINATION. DIAGNOSIS OF FETAL 
PRESENTATION, POSITION, AND ENGAGEMENT OF PRE- 
SENTING PART. EXTERNAL PELVIMETRY. 

The patient should lie upon her back upon the side of the bed or couch, 
with the clothing loosened and the abdomen bare, or covered only with one 
thickness of a bed-sheet, through which it is possible to make a satisfactory 
examination. The examiner should see that his hands are warm, since the 




Fig. 199. — Location of the Fetal Back and Small Parts by External Palpation. 
The left hand displaces the fetus to the left for locating the dorsal plane. — (From 
a photograph taken at the Emergency Hospital.) 



contact of a cold hand with the abdominal wall is apt to excite reflex contractions 
of the abdominal muscles, and even in the uterus. Moderate flexion of the 
thighs will often assist in relaxing the abdominal muscles, and this position 
can often be used to advantage. The bladder and rectum should have been 
emptied recently. We should ascertain as much as possible at the first exam- 
ination, and, in order that nothing be overlooked, we ought to follow some 
definite routine order of examination, as in the case of the internal examination 
of pregnancy (see page 174) and labor (see labor). We should also accustom 
ourselves to palpate with the left as well as the right hand. The order of 



THE EXAMINATION OF PREGNANCY. 



161 



examination here recommended is: (i) Determination of general conditions. 
(2) Location of fetal back and small parts. (3) Palpation of the lower fetal 
pole. (4) Palpation of the upper fetal pole. (5) Location of the cephalic 
prominence. (6) Deep pelvic palpation. (7) Locating anterior shoulder. (8) 
Palpation in breech presentation. (9) Palpation in shoulder presentation. 
(10) Location of the fetal heart. (11) External pelvimetry. Most of the 
methods of abdominal palpation can be carried out while the examiner sits 
at the bedside, facing the patient's abdomen. 

1. General Conditions. — (1) The general condition of the patient should 
first be observed, and evidences of blood changes, pulmonary, cardiac, renal, 




Fig. 200.— Palpating the Lower Fetal Pole by External Palpation. — (From a 
photograph taken at the Emergency Hospital.) 



syphilitic, or tuberculous disease noted; (2) the breasts and nipples are to be 
inspected for lacteal capacity and evidences of previous inflammation in the 
former, and for flatness, inversion, fissure, or erosion of the latter. We pass 
next to the abdomen and determine (3) the direction of the uterine axis, detecting 
any excessive right or left lateral obliquity or other displacement, the result of 
previous inflammations or operation, and (4) the thickness and pendulous 
condition of the abdominal walls. We should then determine by abdominal 
palpation the general shape and size of the uterus; the relation of the fundus 
to the umbilicus and ensiform cartilage; the size of the fetus, and its relation 
to the amount of liquor amnii, and whether the fetus lies vertically, trans- 
versely, or obliquelv in the uterus. This is accomplished by placing the palms 
11 



162 



PHYSIOLOGICAL PREGNANCY. 



of the hands one on each side of the abdomen, and sliding them evenly and 
gently upward and downward over the entire pregnant uterus, from the fundus 
to the pubis and back again to the fundus, at the same time, gently and without 
much pressure, palpating the whole maternal abdomen with the finger-tips 
(Figs. 199 to 206). 

2. Location of Fetal Back and Small Parts. — The next point to be made 
out is the location of the child's back; this can usually be done by palpating 
the whole maternal abdomen with the tips of the fingers, gently and without 
much pressure. Stronger pressure may be necessary to ascertain the amount 
of resistance, mobility, etc., but it should be remembered that strong pressure 




Fig. 201. — Palpating the Upper Fetal Pole by External Palpation. 
photograph taken at the Emergency Hospital.) 



■{From a 



blunts the tactile sensibility of the ends of the fingers. The small parts by 
this method will be felt as small rounded knobs, more or less movable. If the 
examiner will steady the fetus in its long axis, and exert some pressure upon 
the upper pole, the dorsal convexity will be considerably increased, and therefore 
more easily palpated. Another method is to apply moderate deep pressure 
with the flat of the hand on the middle of the abdomen. This displaces the 
fetus toward the side to which its back is turned, and while the pressure is main- 
tained with one hand the examination may be made satisfactorily with the 
other (Fig. 199). In order to make out whether the back of the fetus is turned 
toward the back or front of the mother, it is to be remembered that the fetal 
back offers a broad, smooth convex surface from end to end, while the lateral 



THE EXAMINATION OF PREGNANCY. 



163 



aspect is not convex from end to end, is narrower, and has a deep sulcus be- 
tween head and pelvis. The small parts on one side indicate that the back 
is on the other, except in the case of twins. If small parts can be felt beyond 
either end of the fetus, the presentation is pretty certainly a breech. Certain 
conditions may, when present, make this part of the examination difficult or 
uncertain. A large amount of abdominal fat, hydramnios, and a rigidly con- 
tracted uterus, are some of these conditions. 

3. Palpation of the Lower Fetal Pole. — The hands of the examiner are placed 
flat upon the sides of the abdomen, with the palms toward each other, and 
the fingers toward the feet of the patient, and resting a little above Poupart's 




Fig. 202. — Locating the Cephalic Prominence in Vertex Presentation by External 
Palpation. — (From a photograph taken at the Emergency Hospital.) 



ligament (Fig. 200). When the hands are passed toward each other and also 
toward the cavity of the maternal pelvis, it is usually possible to catch quickly 
the fetal pole, and to manipulate it. The first point to determine, when the 
pole is found, is whether it is head or breech. The head is large, hard, and 
globular, and separated from the trunk by the constriction of the neck; and it 
is, furthermore, the only part of the fetus which sinks into the maternal pelvis 
before labor. The breech always lies above the excavation of the pelvis until 
labor begins. When either fetal pole is found in an iliac fossa, the presentation 
will be transverse. 

4. Palpation of the Upper Fetal Pole. — To accomplish this satisfactorily, 
the position of the hands is in the opposite direction from that just described, the 



164 



PHYSIOLOGICAL PREGNANCY. 



palms being placed facing each other on the upper part of the abdomen, with 
the fingers toward the patient's head (Fig. 201). The head when found in the 
upper segment of the uterus can be subjected to ballottement, and otherwise 
has the characteristics which have been mentioned (Fig. 205). The breech 
in the upper segment is less mobile, more voluminous, and softer than the 
head (Fig. 201). 

5. Location of the Cephalic Prominence. — (1) The hand is pressed trans- 
versely across the maternal abdomen, just above the symphysis, and the head 
thus grasped and palpated (Fig. 202). The occipital side is that at which 
the hand sinks deepest into the pelvis; since the occiput itself is the part of 




Fig. 203. — Deep Pelvic Palpation to Determine the Amount of Engagement of 
the Presenting Part by External Palpation. — (From a photograph taken at the 
Emergency Hospital.) 



the head which, as a rule, is deepest in this cavity. The greatest prominence 
at the brim is, therefore, the forehead, most marked in the occipito-posterior 
position. (2) The right or left hand, with thumb and fingers separated as far 
as possible, grasps the fetal head just above the pelvic inlet (Fig. 202). Since 
the head in primigravidas is usually partially engaged in the pelvic inlet, it is 
advisable to direct the thumb and finger-tips downward toward the pelvic 
cavity. In multigravidae, by reason of the rather high situation of the head, 
the thumb and finger-tips are held more horizontally. In the latter case we 
can assist in the manceuver by steadying the fundus with the disengaged hand. 
The head feels hard and ball-like and can usually be moved from side to side. 



THE EXAMINATION OF PREGNANCY. 



165 



The breech appears soft and irregular. In pelvic presentation the same method 
can be applied to the head lying in the fundus (Fig. 202). In shoulder presenta- 
tion, no definite presenting part being found at the pelvic inlet, the head is 
sought for by gently palpating with short finger-strokes in one or the other side 
of the uterus (Fig. 206). It can then be grasped in the same manner as above, 
and the manoeuver assisted by steadying the breech with the disengaged hand. 
6. Deep Pelvic Palpation. — In primigravidas when the head is engaged in 
the pelvis, and in both primiparae and multiparas when the same condition 
obtains, the method of palpating the cephalic extremity shown in Fig. 203 is 
most useful, especially during labor. Moderate flexion of the thighs, approxi- 




Fig. 204. — Locating the Anterior Shoulder by External Palpation. Right hand 
depresses and raises fundus, while the left palpates for the shoulder. — {From a photo- 
graph taken at the Emergency Hospital.) 



mation of the heels, and separation of the knees greatly assists in relaxing the 
anterior abdominal walls. As pictured in Fig. 203, the examiner stands at 
the side of the bed, facing the patient's feet. The palms of the hands are 
placed on both sides of the lower uterine segment, and the finger-tips of 
both hands are made to enter the pelvic cavity slowly and gently, alongside 
of the head, between it and the pelvic walls. As in Fig. 202, but more satis- 
factorily, the head when engaged in the pelvis can be felt as a hard, oval body 
occupying the latter; the more prominent forehead, on one side, being readily 
distinguished from the less prominent occiput, or nape of the neck, on the 
other. The forehead is especially prominent in occiput posterior positions 



166 



PHYSIOLOGICAL PREGNANCY. 



(Fig. 203). We have no more valuable method of determining bregma, 
brow, and face presentations before dilatation of the os, than that by deep pelvic 
palpation. In bregma presentation incomplete flexions of the occiput and 
forehead are about equally prominent; in brow presentations the occiput is 
more in evidence, while in face presentations it is the most prominent part 
of the fetal head to be palpated. 

7. Location of the Anterior Shoulder. — One hand is placed above the uterus 
upon the fundus, so as to steady the organ and press it into the pelvis. With 
the other hand the anterior shoulder can be recognized as a rounded prominence, 
which when on the left of the median line, indicates a left fetal position, and 




Fig. 205. — Locating the Cephalic Extremity of the Fetus in Breech Presentation 
by External Palpation. — (From a photograph taken at the Emergency Hospital.) 



when on the right, a right fetal position. When the shoulder is less than two 
inches from the median line, the fetal position will be anterior; when more 
than two inches away, posterior (Fig. 204). 

8. Palpation in Breech Presentation (Fig. 205). — The flexed band is pressed 
transversely across the maternal abdomen just at or above the umbilicus and 
the head grasped and palpated (Fig. 205). Or we can proceed as in palpation 
of the upper fetal pole (Fig. 201). The anterior shoulder (Fig. 204), the dorsal 
plane, and small parts (Fig. 199) are palpated practically as in head presenta- 
tions. 



THE EXAMINATION OF PREGNANCY. 



16; 



9. Palpation in Shoulder Presentation( Fig. 206). — The same general prin- 
ciples apply here as in head and pelvic presentations. 

10. Location of the Fetal Heart (Fig. 173). — This may be accomplished 
with the stethoscope, with the phonendoscope, or by the ear alone. The abdom- 
inal wall should be pressed against the uterine tumor, since sound is best trans- 
mitted through a homogeneous solid. This is best accomplished by pressing 
the fundus with one hand, and directing the uterus downward and forward 
(Fig. 173). It is advisable to direct this pressure in such a manner as to bring 
simultaneously the dorsal surface of the fetus as nearly as possible under the 




Fig. 206. — Locating the Cephalic and Podalic Extremities of the Fetus in Shoulder 
Presentation by External Palpation. The left hand grasps the head and the 
right the breech. — {From a photograph taken at the Emergency Hospital.) 



stethoscope. The sounds resemble the ticking of a watch under a pillow, and 
vary from 130 to 140 per minute, being about twice as frequent as those of the 
healthy adult heart. Active movement on the part of the fetus increases the 
fetal heart-rate. If the organ is located on the left, — that is, if the point of 
greatest intensity of the heart sounds is on the left of the median line, — the 
presentation is left; if on the right, the presentation corresponds. If the heart 
is located above the umbilicus, the presentation is pelvic; if below, the head 
will present. Twins show naturally two hearts of different rates, and the sex 
can sometimes be guessed at by remembering that a persistent fetal heart rate 
under 120 indicates a boy; and over that, a girl. In certain dorso-posterior 



168 



PHYSIOLOGICAL PREGNANCY. 



positions, and in some cases of hydramnios, it is occasionally impossible to 
hear the fetal heart. 

EXTERNAL PELVIMETRY. 

In taking the external pelvic measurements the pelvimeter is necessary. 
Two very good instruments in common use are the pelvimeters of Baudelocque 
(Fig. 208) and of Schultze (Fig. 207). The former must be used with caution on 
account of the spring of the metallic arms. The modification of the Baudelocque 
pelvimeter, elliptical in shape, occasionally seen at the instrument-makers, has 
even greater spring than the original, and should be avoided if accurate results 
are desired. The Schultze pelvimeter is of a shape which gives great firm- 
ness, and is convenient to carry in the pocket or obstetric bag. In use the arms 
of the pelvimeter are separated, a rod being taken in each hand, with an index- 
finger on each knob. The knobs are then placed on the two selected points, 

fixed in position, the screw near the handle is 
tightened by an assistant, and the distance 
between the two points is read off on the scale 
attached to the instrument (Fig. 208). The 
patient should be dressed as for bed, and placed 
first in the dorsal position, upon the side of the 
bed or lounge. The physician standing at her 
right side, and holding an arm of the instru- 
ment with the thumb and fingers of each hand 
near the points, applies the latter to the outer 
edge of the anterior superior iliac spines, and 
notes the diameter thus gained (Fig. 208). He 
then pushes the points backward and forward 
along the outer edge of the iliac crest, and notes 
the greatest diameter which can in this way be 
obtained. The woman then turns on her side, 
or abdomen, and the points of the pelvimeter 
are placed on the posterior superior iliac spines, 
which are marked by well-defined dimples, 
and the distance between these is noted. The 
oblique diameter is obtained by placing one of 
the points upon the posterior superior iliac 
spine, and the other upon the anterior superior 
iliac spine of the opposite side. The external 
conjugate is obtained while the patient lies on her left side or stands in the 
erect position. One point is placed in the depression just below the spine of 
the last lumbar vertebra, while the other is placed upon the middle of the 
upper anterior border of the symphysis pubis. The distance between the 
femoral trochanters may be obtained by placing each point as nearly as 
possible upon the most projecting part of each greater trochanter. This last 
is an unimportant diameter. In external pelvimetry we rely upon the fol- 
lowing twelve measurements; the first four of which are most commonly 
used: (1) Interspinous. (2) Intercristal. (3) Between the great trochanters. 
(4) The external conjugate, or Baudelocque's diameter. (5) Right oblique 
diameter. (6) Left oblique diameter. (7) Between the posterior superior 
iliac spines. (8) Between the tubera ischii. (9) Transverse diameter of outlet. 

(10) Antero-posterior diameter of outlet. (11) Length of the symphysis. 

(11) Circumference of the pelvis. 




Fig. 



207. 



-Schultze's 

METER. 



Pelvi- 



THE EXAMINATION OF PREGNANCY. 



169 



i. Interspinous Diameter (Fig. 208). — This is the widest distance between 
the anterior superior iliac spines, and is measured by placing the points of the 
pelvimeter upon the external surfaces of the spines, at the insertion of the sar- 
torius muscles (Fig. 208). In normal pelves this measurement varies from 
g% to io| inches (24.1 to 26.7 cm.). 

2. Intercristal Diameter (Figs. 208 and 209). — This the widest interval 



An/prior 
\ s (/pert or 





Fig. 208. — Measuring the Interspinal Diameter with the Baudelocque Pelvimeter. 



between the iliac crests, and is measured between the most prominent portions 
(Fig. 209). In normal pelves this diameter varies from 10^ to 11^ inches (26.7 
to 29.1 cm.). 

3. Between the Great Trochanters (Fig. 209). — This diameter is the greatest 
distance between the external surfaces of the great trochanters of the femora. 
In normal conditions it measures 12.4 inches (31 cm.), but may even be 11^ 



170 



PHYSIOLOGICAL PREGNANCY. 






inches (29.1 cm.), without indicating pelvic contraction. Because of variations 
in the size of the femoral head, this diameter is the most unreliable one of those 

here mentioned. 

4. The External Con- 
jugate ; Baudelocque's Di- 
ameter( Figs. 211 and 212). 
£L — This is measured from 

the depression just below 
the spine of the last lum- 
bar vertebra, which is 
about one inch above the 
posterior interspinous di- 
ameter, to the point on 
the skin of the mons ven- 
eris in front of the upper 
external edge of the sym- 
physis pubis. In normal 
cases it measures 8 inches 
(20.3 cm.). As a clinical 
index of contracted pelvis 
this diameter is unreliable. 
According to Jewett, how- 
ever, when the external 
conjugate is at or below 6 
inches (15.2 cm.), or even 
below 6J inches (15.8 cm.), 
the pelvis is invariably 
contracted; between 6^ 
inches (15.8 cm.) and 8 
contraction is very uncertain, and must be 
at or above 8 inches (20.3 cm.) the pelvis is 
A certain relationship is said to exist between 



< 

X 

o 
o 

DC 





Fig. 209. — Position of the Points of the Pelvimeter 
for Measuring the Intercristal and Bitrochanteric 
Diameters of the Pelvis. 



Superior ^ 
Spine 



v*&7 KtyMPasiwior 
j!^C <Superi(n'Jpuie 



inches (20.3 cm.) the amount of 
settled by internal measurements: 
almost sure to have ample room. 
the lengths of the ex- 
ternal and internal 
conjugates ; such 

marked variations, 
however, occur be- 
tween the two that 
the external can 
never be relied upon 
as an exact clinical 
index of the internal. 
Litzmann measured 
the external conju- 
gate during life, and 
the internal or true 
conjugate post mor- 
tem in 30 cases, and 

found that there was an average difference between the two of 3 J inches (9.5 cm.). 
In the entire 30 cases, there were variations from 2J inches (7 cm.) to 4-j-g- inches 
(12.5 cm.). 

5 and 6. Right and Left External Obliques (Fig. 210). — The right external 




Fig. 210. — Position of the Points of the Pelvimeter for 
Measuring the Right External Oblique Diameter of the 
Pelvis. 



THE EXAMINATION OF PREGNANCY. 



171 



oblique is measured from the right posterior superior spine of the ilium to the 
left anterior superior spine, and measures 8} inches (22 cm.). The left external 
oblique is the distance from the left posterior superior spine of the ilium to the 
right anterior superior spine, and measures also 8f inches (22 cm.). These 
right and left oblique diameters should be equal or nearly so. In obliquely 
contracted pelves, as the 
single oblique pelvis of 
Naegele, a considerable 
difference may be present. 
In such pelves several 
other oblique measure- 
ments are of value, in order 
to determine differences 
between the two lateral 
halves of the pelvis, al- 
though in these cases, 
more than in any other, an 
external examination is 
necessary to detect the ex- 
act degree of deformity. 
Three additional measure- 
ments are: (1) From the 
posterior superior spine of 
one side to the tuber ischii 
of the other. ( 2 ) From the 
spine of the last lumbar 
vertebra to the anterior 
superior iliac spines of both 
sides. (3) From the pos- 
terior superior spine of one 
side to the great trochanter 
of the opposite side. (4) 
From the lower margin of 
the symphysis to the pos- 
terior superior iliac spines. 
(5) From the middle line 
of the back to both pos- 
terior superior iliac spines. 

7. Between the Poste- 
rior Superior Iliac Spines. — 
This is measured from the 
outer surfaces of these 
spines, and equals norm- 
ally 3} inches (9.8 cm.). 

9. Transverse Diameter 
of the Outlet (Fig. 214).— 

This diameter is rarely referred to, and less often taken, but it is of great 
value in showing contraction at the pelvic outlet in kyphotic and funnel- 
shaped pelves. With the patient in the lithotomy position, the palmar sur- 
faces of the index-fingers are pressed firmly against the inner borders of the 
tuber ischii, and an assistant then measures the diameter with the points of the 
pelvimeter placed on the index-fingers, close to the ischial bones (Fig. 214). 




Fig. 211. — Measuring the External Conjugate Diam- 
eter of the Pelvic Inlet. Diameter of Baude- 

locque. baudelocque pelvimeter. 



172 



PHYSIOLOGICAL PREGNANCY. 



Normally this diameter is 4^ inches (11 cm.). The transverse diameter of 
the outlet may be measured with equal facility by determining the distance 
between the ischial tuberosities. The site of the latter is located by the 
points at which a horizontal line touching the anterior margin, of the anus 
comes in contact with the folds of the thigh. The knobs of the pelvimeter 
are applied at these points, the shanks of the instrument having previously 
been overlapped, and pressed firmly against the subjacent bones. The meas- 
urement thus obtained is normally 4^ inches (11.43 cm.). There should be 
allowed for the soft parts about J inch (0.635 cm.), varying with the thickness of 
the nates. The true transverse diameter of the outlet is therefore 4^ inches 
(11 cm.). 

10. Antero-posterior Diameter of the Outlet. — The woman is placed on her 

side and the examiner introduces 
his index-finger into the vagina, 
with the thumb over the region of 
the coccyx. By moving the latter 
bone back and forth, the location 
of the sacro-coccygeal joint is de- 
termined, and a pencil mark is 
made upon the superjacent skin. 
One button of the pelvimeter is 
applied over this mark, while the 
other rests within the vulva, and 
upon the lower border of the sym- 
physis. The straight or antero- 
posterior diameter of the outlet is 
thus determined, and is normally 
5 inches (12.5 cm.). About J inch 
(1.5 cm.) must be subtracted 
from the thickness of the coccyx 
and soft parts to obtain the actual 
or net measurement. The preced- 
ing method is known as Breisky's, 
and is endorsed by Skutsch. This 
diameter can usually more readily 
be measured directly with the fin- 
gers internally (Fig. 213). 

11. Length of the Symphysis 
(Fig. 218). — This is important in 
determining the depth of the true 
pelvis, and in assisting in the estimation of the true from the diagonal conjugate. 
It is measured with a pelvimeter by pressing one point closely down upon the 
center of the upper border of the symphysis, and the other point against the 
center of the subpubic ligament. It can also be estimated with the fingers 
(Fig. 218). 

12. External Circumference of the Pelvis. — This is measured with the tape- 
measure over the middle of the symphysis, just below the iliac crests, and across 
the middle of the sacrum, and is usually about 35-5- inches (88.75 cm.). 

13. The True Conjugate Measured Externally. — In thin, non-pregnant women, 
and in the early months of gestation, the true conjugate may occasionally be 
estimated directly from without, by placing the palmar surface of the hand 
on the hypogastrium, and pressing backward until the tips of the fingers reach 




Fig. 212. — Point (x) Below the Spine of the 
""Last Lumbar Vertebra used to Indicate 
the Posterior Extremity of the Exter- 
nal Conjugate of the Pelvic Inlet. 



THE EXAMINATION OF PREGNANCY. 173 

the promontory. The hand is then marked over the pubes with a finger-nail 
of the disengaged hand, and after allowing for the thickness of the abdominal 
walls and pubes, the estimate is made. The method is of little practical value. 
A graduated rod with a blunt surface for pressing against the sacral promontory 
may be substituted for the hand. 

These external measurements are not trustworthy, since errors of as much 
as two inches may occur. They rather point out the general shape of the 
pelvis and not the exact pelvic capacity. Baudelocque's conclusion that the 
external conjugate minus from 2-J to 5 inches (7 to 12.5 cm.) equals the internal 
true conjugate is now known to be untrustworthy. Of the above the diam- 
eters of the most practical importance are the (1) interspinal, (2) intercristal, 
(3) external conjugate, (4) transverse of outlet, and (5) antero-posterior of 
outlet. A marked diminution in the interspinal and the intercristal diameters 
leads to the suspicion of a transversely contracted pelvis. If the intercristal 
diameter is no greater than the interspinal, or if it is less, the pelvis is probably 
rachitic. A difference in the lateral halves of the pelvis is shown by a difference 
in the oblique diameters; while a notable diminution in the external conjugate 
shows that we have to deal with a flattened pelvis. Unlike the case of the 
true conjugate, it is not safe to make inferences as to the length of the internal 
transverse diameter of the lesser pelvis, from these external measurements, 
because there are too many opportunities for disparities in the shape and size 
of the ilia. The nearest approximation to a rule, which, however, holds good 
in not more than fifty per cent, of cases, is that the interspinous line is twice 
as long as the transverse diameter of the lesser pelvis. These external meas- 
urements, however, have some value in other directions. Thus, if the spine 
and crest measurements exhibit little or no difference, the pelvis in question 
is probably rachitic. The external measurements should always be compared, 
for if each has the normal length, the lesser pelvis should be regarded as nor- 
mal. But if the interspinous line is as long as the intercristal, or longer, the 
external conjugate is unnaturally short, and these disparities indicate the exist- 
ence of a flat, rachitic pelvis. Again, if the three external measurements are 
in the normal proportion to one another, but are all unnaturally short, they 
indicate the existence of a generally contracted pelvis, the most common 
variety in the United States. 



INTERNAL OR VAGINAL EXAMINATION. INTERNAL PELVIMETRY. 

An internal pelvic examination is imperative in all primigravidae, and in 
others upon whom the least suspicion of pelvic deformity rests. The same 
care in the preparation of the patient and of the physician's hands should be 
taken at this time as in internal examinations during labor. 

Objects of the Examination. — In the internal or vaginal examinations we 
strive to (1) confirm the findings of the external examination in regard to (a) 
the actual existence of pregnancy; (b) the period of gestation; (c) the probable 
date of labor; (d) the viability of the fetus; (e) and the presentation, position, 
and engagement of the head. (2) In addition, we seek information as to the 
conditions of the soft parts, as to congenital defects, pathological growths which 
may obstruct or complicate labor, or injuries resulting from previous deliveries. 
(3) The possibility of a placenta prsevia should always be kept in mind. (4) 
The size of the pelvis should be estimated, and (5) the obstetric diagnosis con- 
firmed and completed. 



174 PHYSIOLOGICAL PREGNANCY. 



INTERNAL PELVIMETRY. 

For internal pelvimetry many instruments have been devised, but the best 
of all is the educated hand. We have, therefore, manual and instrumental 
pelvimetry. After the usual disinfection of the vulva, and of the hands and 
arms of the physician, the patient is placed in the lithotomy position, with 
the hips projecting well over the edge of the bed or table. The first and second 
fingers are then introduced into the vagina and passed well upward toward 
the promontory of the sacrum. With these two fingers the general conforma- 
tion and capacity of the pelvis, the pelvic inclination, the depth, inclination, 
and thickness of the symphysis pubis, the shape and curve of the sacrum, the 
flexibility of the coccyx, and, with the assistance of the external pressure upon 
the fundus, any marked disproportion between the fetal head and pelvis, can be 
determined (Figs. 230 and 231). Several internal pelvic diameters will demand 
measurement in cases of suspected deformity, although usually the diagonal 
and true conjugates are a sufficient clinical index of the pelvic capacity. These 
diameters are: (1) the sacro-pubic; (2) the pubo-coccygeal; (3) the transverse 
diameter of the outlet; (4) the diagonal conjugate; (5) the true conjugate; 
(6) the transverse diameter of the inlet. 

1. The Sacro-pubic Diameter (Fig. 213). — With two fingers in the vagina, the 
tip of the second finger seeks and presses firmly against the sacro-coccygeal 
joint, and the radial edge of the hand is brought up firmly against the subpubic 
ligament. A finger-nail of the other hand then marks the point of junction 
at the apex of the pubic arch (Fig. 213). The vaginal fingers are now with- 
drawn, and the distance between the two points of contact is measured with 
a pelvimeter or tape-measure. Normally this diameter measures 4^ inches 
(11. 5 cm.). 

2. The Pubo-coccygeal Diameter. — This is measured in the same manner as the 
above, but from the subpubic ligament to the tip of the coccyx. In anterior 
positions of the coccyx this diameter is about 4^ inches (11.5 cm.), but recession 
during expulsion of the head may readily increase the diameter to 5^ inches 
(14 cm.). 

3. Transverse Diameter of the Outlet. — This has been described under 
external pelvimetry (page 168, Fig. 215). During labor, or under partial 
anesthesia, this diameter can be estimated by pushing the half-fist between 
the ischial tuberosities and partly into the vaginal orifice. The width of the 
four fingers or knuckles is then compared with the bisischial space. (Compare 
Manual Pelvimetry.) 

4. The Diagonal Conjugate (Fig. 214). — This is the distance from the center 
of the sacral promontory to the subpubic ligament. To measure it manually, 
the first and second fingers of either hand are introduced into the vagina, and 
the sacral promontory is sought for. Some experience is necessary to be able 
to recognize the promontory, and care should be taken not to mistake a " false 
promontory" for the true one. Unless the deformity is extreme it will be 
the second finger which touches the promontor}^ Keeping the finger in contact 
with the latter, the radial side of the first finger or hand is held firmly against 
the subpubic ligament, while the exact point of contact is marked by the finger- 
nail of the first finger of the other hand (Fig. 214). The fingers are then with- 
drawn, and the distance is measured with the pelvimeter (Fig. 216) or tape, 
the examining hand being held in the same relative position. This diameter in 
normal pelves measures 5^ inches (13.5 cm.). 

5. The True Conjugate. — The true conjugate can be estimated from the 



THE EXAMINATION OF PREGNANCY. 



175 




Fig. 213. — Digital Method of Measuring the Antero-posterior Diameter of the 
Pelvic Outlet. — {From a photograph.) 




Fig. 214.— Digital Method of Measuring the Diagonal Conjugate of the Pelvic 

Inlet. — (From a photograph.) 



176 



PHYSIOLOGICAL PREGNANCY. 



diagonal conjugate, by constructing a triangle formed by the two conjugates 
and the symphysis pubis, of which the diagonal conjugate corresponds 
nearly to the hypothenuse, and the true conjugate to the base. The diagonal 
conjugate, the known quantity, is the longest of the three sides, and the true 
conjugates, the unknown quantity, can be obtained from it by subtracting on 
an average i inch (2.5 cm.). The amount to be deducted, however, will vary 
with the height, thickness, and inclination of the symphysis and the height of 
the sacral promontory. When the symphysis is i-| inches (3.75 cm.) or over, 
J inch (1.905 cm.) should be subtracted from the diagonal conjugate; and when 
it is less than ij inches (3.75 cm.), a little less is to be subtracted. The esti- 




Fig. 215. — Method of Measuring the Transverse Diameter of the Pelvic Outlet. 
The points of the pelvimeter are placed on the palmar surfaces of the tips of the index- 
fingers. See diagram, upper left of illustration. — (From a photograph.) 



mation of the true conjugate by this plan can only be approximated, since it 
depends upon so many variable quantities. The method of taking the height 
of the symphysis is described on page 173. For determining the thickness of 
the symphysis the pelvimeter of Skutsch, or one of its modifications, may be 
used (Fig. 220). It can be roughly estimated, of course, by the thumb and 
finger of the accoucheur (Fig. 218). The normal angle between the true conju- 
gate and the symphysis has been estimated at 105 degrees. After the physi- 
cian has made it a habit to combine internal pelvimetry with vaginal examina- 
tion, he will soon learn to recognize and appreciate departures from the normal 
type. An important point, commonly misunderstood, is that the obstetric con- 



THE EXAMINATION OF PREGNANCY. 



177 




jugate is the smallest amount of available intrapelvic space in the antero- 
posterior diameter, whether measured from the true promontory or some other 
point, as a false promontory or displaced lumbar vertebra. 

True Conjugate with Pelvimeters (Skutsch). — Many pelvimeters have been 
devised for measuring the true conjugate. 
These instruments, as a rule, do not take 
cognizance of other internal diameters. 
Two instrumental methods for measuring 
the true conjugate give practical results : 
viz., those of Skutsch and Farabeuf re- 
spectively. The measurement which the 
former gives is known as the interno- 
external, and is not so accurate as that 
obtained by the direct method with the 
latter or Farabeuf 's instrument. (See 
page 178 and Fig. 219.) Eight years' ex- 
perience with the latter instrument has 
satisfied the author that it is the most 
accurate instrument for the purpose at 
present in existence. 

The Skutsch pelvimeter is about the 
shape of a pair of calipers (Fig. 220). Its 
internal arm is of steel, with a spatula- 
like tip, while its fellow is of pure lead 
covered with india-rubber tubing. To de- 
termine the true conjugate, the woman is 
placed in the dorsal position, with knees 
elevated and legs spread apart. The sac- 
ral promontory is first located, and then 
the projecting point on the internal aspect 

of the symphysis. A point is then selected upon the mons veneris correspond- 
ing to an imaginary continuation of the true conjugate, and indicated by a 
crayon mark. The internal or steel arm is then introduced into the vagina, 
with the finger as a guide, and its spatula-like tip applied firmly to the pro- 
montory and there maintained, 
while with the other hand the 
lead arm is given such a contour 
that its terminal knob is placed 
near the marked spot upon the 
mons. The external hand then 
gives the pelvimeter a slight 
twist upon its axis, after which 
the knob of the external arm 
may be pressed accurately upon 
the marked spot. The pelvim- 
eter is then locked and with- 
drawn. The distance is meas- 
ured by the scale accompanying 
the instrument. The internal arm of the pelvimeter is then applied to the 
internal aspect of the symphysis, and its distance from the marked point upon 
the mons veneris is determined, in the same manner as was the first measure- 
ment. Subtraction of the small from the large measurement gives the length 

\2t 



Fig. 216. — Measuring the Distance 
from the End of the Second Fin- 
ger to the Mark Made upon the 
Radial Border of the Hand. 




Fig. 



217. — Stein's Pelvimeter for Measuring 
Directly the True Conjugate. 



178 



PHYSIOLOGICAL PREGNANCY. 



~"'~^ 



of the true conjugate. The Skutsch pelvimeter is in like manner used to measure 
the transverse diameter of the pelvic inlet. (See page 221.) 

True Conjugate with the Farabeuf Pelvimeter. — This resource was intro- 
duced into pelvimetry by Farabeuf * for the purpose of lengthening the index- 
finger, in case the accoucheur should be unable to reach the promontory, either 
by reason of the shortness of his finger, or because of unusual dimensions of 
the pelvis. While fingers of average length are sufficient for pelvimetry in 
contracted pelves, this is by no means necessarily the case in general pelvim- 
etry, and therefore the device of Farabeuf is excellent in routine obstetrical 
practice. The custom of reinforcing the finger with a vesical sound is open 
to criticism, from the fact that it may be given a wrong direction; and a further 
disadvantage is the absence of a device to indicate the exact position of the 

symphysis. The thimble-like 
pelvimeter consists of two deli- 
cate steel arms, which are par- 
allel for a short distance, but 
which then diverge, and after- 
ward roughly assume the con- 
tour of a tapering forefinger. 

m f | . This frame is provided, on its 

inferior surface, with two in- 
complete rings, designed to fit 
the first and second phalanges 
of the exploring finger. The 
elasticity of the steel arms per- 
mits the rings to slip over a finger 
of any normal dimensions. At- 
tached near the extremity of this 
steel frame is a delicate horse- 
shoe-shaped piece of steel, which 
turns in either direction, up or 
down, and which constitutes the 
extension to the exploring finger 
( Fig. 219). The parallel portion 
of the steel arms also constitutes 
a groove, along which slides the 
measuring rod, which is bent at 
its terminal end into a right 
angle. This bent portion is in- 
tended to enter the urethra in order to abut against the internal aspect of the 
symphysis. The proximal end is provided with a ring, while the upper surface 
of the rod has a graduated index (Fig. 219). With this pelvimeter the obstetrical 
conjugate can be measured directly. The steel arms are introduced against 
the promontory, followed by the passing of the measuring rod into the bladder 
(Fig. 219). 

6. Transverse Diameter of the Inlet (Fig. 221). — Exact measurements of the 
transverse diameter of the brim are as yet hardly practicable. The pelvimeter of 
Skutsch is an example of what has been done in this direction (Figs. 220 and 221). 
To obtain the transverse diameter at the pelvic inlet with this instrument, the 
woman is placed in the dorsal position with her extremities in leg-holders. 
The fingers of the left hand are introduced within the vagina and along the 
* " Gaz. Hebdom. de Med. et Chir.," June, 1S89. 




Fig. 218. — Measuring the Height and Thick- 
ness of the Symphysis with the Fingers. 
This procedure is also useful to determine the 
amount of engagement of the presenting part 
or the effect of the uterine contractions in causing 
descent of the head or breech. 



THE EXAMINATION OF PREGNANCY. 



179 




Fig. 219. — Direct Instrumental Method of Measuring the True Conjugate op 
the Pelvic Inlet with the Farabeuf Pelvimeter. — (From a photograph.) 




Fig. 220. — Measuring the True Conju- 
gate op the Pelvic Inlet with the 
Skctsch Pelvimeter. 



Fig. 221. — Measuring the Trans- 
verse Diameter of the Pelvic 
Inlet with the Skutsch Pelvim- 
eter. 



180 



PHYSIOLOGICAL PREGNANCY. 




Fig. 222 —Direct Internal Manual Pelvimetry in a Normal Pelvis. The width 
^^.^roZ^L^pU, N ° te tHe free SpaCe b ~ the P— ^ »S 




Fig 223.— Direct Internal Manual Pelvimetry 
diameter of the closed fist is 4 inches (10 cm ) 
tront and sides of the fist.— (From a photograph ) 



in a Normal Pelvis. The long 
Note the unoccupied room to the 



THE EXAMINATION OF PREGNANCY. 



181 



linea arcuata, 'while the right hand locates the point at which an imaginary 
continuation of the transverse diameter would transfix the skin in the region 
of the hip. This point is indicated by a crayon mark. The error in the deter- 
mination of this point is said to be very slight. The internal arm of the pel- 
vimeter is now introduced within the vagina, and its tip is applied to the left 
extremity of the transverse diameter, while the knob of the lead arm is similarly 
applied over the hip and the short measurement taken. The steel arm within 
the vagina is now reversed, so that its convexity faces about; the opposite 
extremity of the transverse diameter is then located, and the long measure- 
ment made. The difference between the two gives the diameter sought. An 
internal measurement sometimes taken in order to estimate the transverse 
diameter of the pelvic brim is that of Lohlein. With two fingers in the vagina, 




Fig. 224. — Direct Internal Manual Pelvimetry in a Normal Pelvis. The long 
diameter of the fist as thus placed in the pelvis measures 4 inches (10 cm.). Note 
the space between the promontory and the knuckle of the small finger. — (From a photo- 
graph.) 



the distance from the center of the ligamentum arcuatum to the upper anterior 
angle of the great sacro-sciatic notch is taken. According to Lohlein, this is 
f inch (2 cm.) less than the transverse diameter of the inlet. The practised 
hand will soon learn to appreciate any notable transverse contraction in pal- 
pating the lateral pelvic walls. 

Internal Manual Pelvimetry. — Internal manual pelvimetry comprises pal- 
pation of the pelvic canal by the fingers introduced within the vagina, and 
measurement of the pelvic diameters by the aid of the entire hand. Palpation 
of the pelvic canal serves to detect the presence of objects which obstruct the 
lumen of the pelvic canal, such as abnormally long bony prominences. But 
unless favored by circumstances which render possible the introduction of the 
entire hand into the vagina, such as large size and great distensibility of the 
latter, the value of mere palpation of the pelvic canal is not great. 



182 



PHYSIOLOGICAL PREGNANCY. 



For a number of years the author has practised a variety of manual pelvim- 
etry shown in figures 222 to 226. It necessitates the introduction of the 
whole hand into the pelvis, a distensible vagina, and narcosis of the patient. 
It is inapplicable in nulliparous patients, and in many primigravidae before 
labor sets in, but can be used to advantage in most multigravidae, and in all 
parturients. In all primiparae and many multiparas considerable care and 
time must be used in the dilatation of the vagina, so as to avoid rupture of 
that organ or of varicose veins so often present. Troublesome venous hemor- 
rhage from the latter source once occurred in my practice from a too rapid 
dilatation. As the illustrations indicate, the measurements of the pelvic inlet 
are!- compared with the known circumference and diameters of the tightly 




Fig. 225. — Direct Internal Manual Pelvimetry in a Generally Contracted Pelvis. 
Note that the long diameter of the fist reaches from promontory to symphysis. Also 
that the circumference of the fist almost blocks the pelvic inlet. — (From a photograph.) 



closed fist. When applicable, the method is the most positive and satisfactory 
of the internal means for determining the available space at the inlet. 

It should not be forgotten that pelvic contraction is usually relative, not 
absolute, and that the size of the fetal head is just as important as the size 
of the pelvis. The size and compressibility of the head, and whether it can 
be made to enter the pelvic brim, are factors that should never be neglected. 
(See Cephalometry.) Finally, the importance in doubtful cases of a thorough 
examination under full anesthesia, and by an experienced accoucheur, cannot 
be overestimated. It is hardly necessary to point out all the refinements of 
diagnosis in the various forms of pelvic deformity. The educated hand will 
recognize the difference in the respective lateral pelvic walls, which accom- 
panies the obliquely contracted pelvis (Naegele) ; the converging walls and 
approximated ischial tuberosities, which characterize the funnel-shaped pelvis 



THE EXAMINATION OF PREGNANCY. 



183 



(Roberts) ; the presence of bony tumors, etc. The student who has mastered the 
principles of pelvimetry, and the descriptive classification of pelvic deformity, 
will not need exact instruction for every possible case. 

RONTGEN PELVIMETRY. 

The x-rays are able to detect anomalies of the bony pelvis, including narrow- 
ing of the inlet. We therefore possess a new resource in pelvimetry. Accord- 
ing to Bouchacourt, the rays give us three species of information: (i) As to 




Fig. 226. — Internal Direct Manual Pelvimetry in a Flattened and Generally 
Contracted Pelvis. Note that the fist almost fills the pelvic inlet. — (From a photo- 
graph.) 



the presence or absence of deformity in general. (2) As to whether the deformity 
is a symmetrical or an asymmetrical one. (3) As to the nature of the deformity.* 
To practise Rontgen pelvimetry, the woman is placed upon the plate in a some- 
what reclining position, the tube being above and in front of her; or she may 
lie in the lithotomy position, with the plate under the ischial tuberosities, if 
possible at a right angle with the pelvic axis, the tube being above the woman 
in a line with the said axis. Freund speaks of a third position — namely, the 
* "L'Obstetrique," 1900, v, pp. 20-34. 



184 PHYSIOLOGICAL PREGNANCY. 

Trendelenburg — as specially adapted for pelvic photography. Finally, if a 
picture of the rear of the pelvis is desirable, the patient must lie prone with 
the plate beneath and the tube above her. Williams * gives the following 
method of his own devising, for measuring the transverse diameter of the pelvis 
at the inlet. The principle of this method is to photograph the two halves 
of the pelvis separately, but on the same photographic plate. The patient 
lies upon a stretcher in the supine position, with the plate OA^er the abdomen, 
and the inlet of the pelvis about parallel with the plate. When the right side 
of the pelvis is being taken, the left half is protected by a sheet of lead beneath 
the plate. With the aid of a plumb-line, the tube is placed as nearly as possible 
directly under the right border of the superior brim of the pelvis, in the line 
of the pelvic axis and i\ inches (3 cm.) to the right of the median line. If 
the tube is at least 24 inches (60 cm.) from the plate, and as nearly as possible 
just above the point to be determined, the error in the photograph will be slight. 
After the exposure of the right half has been made, the sheet of lead is shifted 
so as to cover this half, and the left side is photographed in the same manner. 
This method eliminates certain errors which will result if the entire pelvis is 
photographed at once. 

PELVIGRAPHY. 

Attempts have been made to depict the entire pelvic cavity during life 
by some method of graphic representation. As far as I know, but two such 
methods have ever been proposed; these are skiagraphy of the pelvis, and the 
geometrical method of Neumann and Ehrenfest, assistants of Professor Schauta 
(Vienna). Skiagraphy of the pelvis is described under the sections Rontgen 
Pelvimetry (page 183) and Rontgen Cephalometry (page 186). 

The geometrical method consists in taking a series of measurements of certain 
pelvic diameters, and plotting the size and outline of various pelvic planes. 
The two transverse diameters and the sagittal plane are sufficient to give a com- 
plete notion as to the individuality of the pelvis. The authors just mentioned 
employ for this purpose an instrument termed by them a pelvigraph. The 
principle involved in the construction and application of the pelvigraph is 
that of the parallel rulers, one number representing a palpator for the localiza- 
tion of points within the pelvis, while the other is provided with a water-level 
and a dial index. There are several palpating arms, the peripheral portions 
of which are bent in various curves or angles, to reach different parts of the 
pelvis; but the proximal portion and the terminal button are always in the 
same axis. The various measurements, angles, etc., are plotted upon drawing- 
paper as soon as they are determined, and in this manner the entire sagittal 
plane is reproduced on paper. The transverse diameters should then be 
measured. This method may be found fully described and illustrated in the 
" Monatsschrift fur Geburtshulfe und Gynakologie," 1900. 

Fabre's Method. — In 1900, Fabre, of Lyons, described before the Interna- 
tional Medical Congress at Paris a method devised by him for measuring the 
superior strait, which he termed metric radiography. Exact mensuration 
with radiography is of course impossible, as the image varies with the distance 
between the ampulla and the various positions of the pelvis. But it is possible 
to measure the dimensions approximately by the method about to be described. 
Four rulers of metal, each provided with a certain number of saw-like teeth, 
form a square about the pelvis. The posterior ruler is opposite the posterior 
superior ischial spines, the anterior lies horizontally in front of the upper por- 
* "The Rontgen Rays in Medicine and Surgery," 1901, p. 378. 



THE EXAMINATION OF PREGNANCY. 



185 



tion of the pubis, etc. A skiagram is then made, and the shadows of the teeth, 
which should be exactly opposite to one another, may be joined by straight 
lines, dividing the area of the pelvic shadow into minute squares, whereby the 
dimensions desired may be measured approximately. 

Indirect Pelvimetry by Measuring the Sternum. — It has been claimed recently 
by Kurz * that the true conjugate and the sternum of a woman measure so 
nearly alike that the error is less than i cm. (0.4 in.). This law applies to both 
normal and contracted pelves. In very many instances the difference between 
the two measurements was not over 1 mm. The length of the sternum should 
therefore possess considerable diagnostic value if it could be readily and accu- 
rately measured. 




Fig. 227. 



-Method of Measuring the Degree of Pelvic Inclination. 
(Instrument of Neumann and Ehrenfest.) 



Cliseometry. 



CLISEOMETRY. 

Cliseometry is the art of measuring the size of the angle of inclination of 
the planes of the pelvic inlet and outlet. For many years obstetricians have 
sought a practical and trustworthy method for determining these angles, but 
up to the present time the results have concerned anthropology, rather than 
practical midwifery. Some authorities have seen in cliseometry a valuable 
prospective resource in the differential diagnosis of pelvic deformities, while 
others believe that the subject of forceps-traction should benefit most from 
increased study of the inclination. Cliseometers have been devised by Naegele, 
Ritgen, Prochownik, and others, but no one apparatus has ever attained any 
considerable degree of recognition. Sources of error, cumbrousness, and general 
* " Centralbl. f. Gynakol.," April 14, 1900. 



186 PHYSIOLOGICAL PREGNANCY. 

impracticability have thus far attended all attempts to systematize and popu- 
larize cliseometry. Neumann and Ehrenfest * have introduced a device for 
measuring the pelvic inclination, which they term a cliseometer (Fig. 227). It 
consists of a rigid curve (A), which carries at one end a hollow cylinder rod 
(B), so disposed that it lies directly in the axis of the free extremity of the 
curve, which is armed with a knob (C) ; the hollow cylinder contains a solid 
rod (D), which slides up and down, and is armed with a second knob (F). The 
two knobs are naturally in the same axis. The upper extremity of the moving 
rod contains a disc (G), which rotates in the direction of the length of the rod. 
The periphery of the disc is divided into degrees. Above and below are zero 
marks, and the numbering is so arranged that there are four quadrants of 90 
degrees each. The disc is also provided with a water-level and an index. When 
the cliseometer is so placed that the axis in which the knobs lie is horizontal, 
the index points to o. If the knobs are applied to the points used in measuring 
the external conjugate with a pelvimeter, and the disc is then rotated until 
the water-level is horizontal, the zero points are also horizontal. The angle 
made by the cylindrical rod and knobs with the horizontal plane, or diameters 
between the zero marks, represents the inclination of the plane of the inlet. f 

CEPHALOMETRY. 

Various procedures have been devised for the determination of the diameters 
of the fetal skull, especially the biparietal and the bitemporal. Attempts 
have been made to measure the skull directly — that is, through the intervening 
soft parts ; to estimate the size of the skull through measurements of more 
accessible fetal structures; and, finally, to estimate the cranial dimensions by 
the duration of pregnancy. 

1. From the Period of Gestation. — Dubois's Method. — From numerous meas- 
urements of the fetal skulls after premature deliveries, controlled by the supposed 
duration of pregnancy, Dubois arrived at the following relationship between 
the month of gestation and the biparietal diameter: seven months, 2-i inches 
(7 cm.); eight months, 3^ inches (8 cm.); eight and a half months, 3-i inches 
(8.5 cm.); term, 4 inches (9 cm.). Unfortunately for this relationship, we 
cannot usually determine the duration of pregnancy, and therefore but little 
practical benefit is derived from the application of such a method to fetometry. 

2. From the Length of the Fetus.— Ahlfeld's Method (Fig. 189).— In 1871, 
Ahlfeld sought to measure the length of the fetus through the abdominal wall, 
and to calculate the cranial diameters from the known relationship of the latter 
to the fetal length. This method is unreliable and has been abandoned. 

3. Direct Abdominal Cephalometry. — Perret's Method (Fig. 228). — Perret was 
the first to practise the measurement of the fetal head through the abdominal 
wall. He used an instrument devised for this purpose, and termed by him a 
" cephalometer " ; the process itself he calls "external cephalometry." The 
foundation of this method was laid in the results of craniometry of the newly 
born. Numerous measurements had shown Perret that whatever the length of 
the biparietal diameter, the occipito-frontal measurement is approximately 1 inch 
(2.54 cm.) longer; so that if it were possible to measure the occipito-frontal 
diameter in titer 0, the shorter measurement could be calculated with ease. 
For the practice of external cephalometry, or the measurement of the occipito- 

* " Monatsschrift f. Geburts. und Gynakol.," 1900, vol. xi. 

t The instrument of Neumann and Ehrenfest is made by M. Schurr, Vienna, IV Schaum- 
burgerstrasse, No. 7a. I obtained my instrument through the Kny-Scheerer Co.', New York. 



THE EXAMINATION OF PREGNANCY. 



187 



frontal diameter of the fetus through the abdominal wall, the cephalometer 
devised by Perret is the 
only instrument, as far as 
known, which has ever been 
employed. This apparatus 
is simply a spherical com- 
pass, such as is sometimes 
used in external pelvim- 
etry, but the knobs which 
arm the branches of a pel- 
vimeter are replaced by a 
special device for overcom- 
ing the difficulties which are 
incident to mensuration 
through the thick abdom- 
inal wall (Fig. 228). Per- 
ret 's description of this de- 
vice is as follows*: "At the 
extremity of each branch is 
a flattened blade, so shaped 
as to be held readily be- 
tween the fingers. These 
little blades revolve on their 
axes in slots which exist in 
the tips of the branches of 
the compass. On account 
of this mobility, the fingers 
of the operator enjoy a cor- 
responding freedom of movement 




Fig. 22S. — Perret' 



Method of Cephalometry and 
Instrument. 



With the fingers in position, that end of the 
blade which corresponds to the pal- 
mar surface and projects beyond is 
furnished with a convex button." 

Perret 's method of using his 
cephalometer is as follows: The 
woman is placed on her back, and 
the operator applies his hands to 
each side of the abdomen, just as 
when seeking to determine whether 
or not the head is engaged (Fig. 
228). If engagement has occurred, 
the procedure must be abandoned. 
Otherwise the operator begins to 
palpate with the short movable 
blades (which furnish the tips of 
the branches of the cephalometer) 
the head between the terminal pha- 
langes of the middle and ring fingers 
of both hands. As the palpating 
finger-tips locate the head, an at- 
tempt is made to press the cephalometer buttons against the forehead and occiput 
of the child. When this has been accomplished, the distance is read off on the 

* " L'Obstetrique," Nov., 1S99. 




Fig. 229. — Measuring the Thickness of the 
Anterior Abdominal Wall. 



1 88 PHYSIOLOGICAL * PREGNANCY. 

scale of the apparatus. The thickness of the abdominal wall is next measured 
directly, by pinching up a fold of the latter, and is deducted from the fetal 
measurement (Fig. 229). The result should be the occipitofrontal diameter 
of the child's head. If now we subtract 1 inch (2.54 cm.), we obtain the bipari- 
etal diameter. The cephalometer has been in constant use in the Tarnier clinic 
in Paris for a number of years. Numerous published reports of results exhibit 
great diversity in regard to the practical utility of the instrument. In the 
hands of Perret and others the results are surprisingly good, the error between 
the intrauterine and extrauterine measurements being insignificant in the 
majority of cases; so that in the hands of one specially trained, cephalometry 
may be termed a practical success. On the contrary, others have published 
series of cases in which the error was so great as to invalidate the results of the 
method for ordinary practice. What has thus far been said of Perret 's cephal- 
ometry refers only to labor at term, the mensuration having for its immediate 
object the determination of disparities between the measurement of the head 
and pelvis. There is, however, a second and equally important indication for 
cephalometry in connection with artificial premature delivery. Given the 
dimensions of a contracted pelvis, cephalometry should determine the maximum 
size of the head compatible with natural delivery, and indicate the period at 
which pregnancy should be terminated. 

The ratio between the two cranial diameters of the fetus holds good for 
the seventh, eighth, and ninth months, the difference, 1 inch (2.54 cm.), being 
in reality the average difference of all skulls having a biparietal diameter of 
from 3 to 3^- inches (7.62 to 8.89 cm.). Labor must be interrupted, of course, 
before the biparietal diameter becomes longer than the true conjugate. The 
results of Perret and others, in this department of obstetrics, appear to show 
that his method is of undoubted value in aiding in the choice of that moment 
for the interruption of pregnancy which shall be most advantageous for the 
interests of mother and child alike. 

4. Manual Engagement of the Head. — Mullens Method (Fig. 230). — The 
relations which subsist between the head and pelvis may often be determined 
by various manual procedures. The so-called method of M tiller has been 
brought into regular and systematic use by prominent obstetricians of Paris, 
under the name of " palper-mensurateur ," given it by Pinard. According to 
Budin, it is sufficient to make an attempt to engage the head in the pelvis, by 
pressure exerted through the abdominal wall, as in Hofmeier's method for 
securing the engagement of the head during labor. (See Labor.) After the 
bladder and rectum have been emptied, the accoucheur places a hand on 
each side of the hypogastrium (Fig. 232) and the head in relation with the 
inlet. Pressure is then made in the axis of the superior strait, so that the head 
is forced into the pelvic cavity. If this engagement can be brought about, 
it is evident that labor should be normal. The manceuver is disagreeable to 
many women, and is also difficult of execution if the abdominal walls are thick 
and resistant, but it renders real service, giving valuable information to the 
physician. I have found it more reliable to introduce the whole hand into the 
vagina, and with the fingers spread over the head to have an assistant exert 
pressure on the hypogastrium to secure engagement of the head (Fig. 232). 
The internal hand then estimates the relation between the size of the head 
and the inlet. Perret, in comparing his method of cephalometry with the 
" palper-mensurateur ," states that it cannot be applied in nervous women, in 
cases of vicious insertion of the placenta, hydramnios, thick abdominal walls, 
or in any case after labor has begun. It is, of course, applicable in head 



THE EXAMINATION OF PREGNANCY. 



189 








\ 




Fig. 230. — Determining the Capability of the Head to Engage in the Pelvic Inlet. 
Muller's Method of Cephalometry. 



w 




/ 



\ V 









Fig. 231. — Determining the Capability of the Head to Descend into the Pelvis. 
Muller's Method of Cephalometry. 



190 



PHYSIOLOGICAL PREGNANCY. 



presentations only. The "palper-mensurateur" also gives false information at 
times. Thus, it appears to indicate that delivery is impossible in cases in which 
the pelvis is normal, and failure to engage is due to trouble higher up (false 
lumbar promontory, tumors, etc.). 

5. Internal Instrumental Cephalometry. Farabeuf's Method. — This is appli- 
cable only in a small proportion of cases, in which there is pelvic contraction 
and non-descent of the head, labor being well under way. A special instrument 
is then used to measure the head, and thus determine whether or not an indi- 
cation for operation is 
present. Farabeuf's in- 
strument is termed by him 
1 ' prehenseur levier men- 
surateur" It comprises 
two blades similar to 
those of the ordinary for- 
ceps, but joined to the 
shanks at a right angle. 
Thus, instead of traction, 
the force exerted is one of 
leverage, the lower border 
of the symphysis serving 
as a fulcrum. By the aid 
of this instrument the 
fetal head can be tilted 
into the pelvic cavity, un- 
less a certain degree of 
disparity exists; and if 
such disparity is present, 
we have a certain indica- 
tion for operation. 

6. Internal Manual 
Cephalometry. — A fairly 
accurate estimate of the 
size of the fetal head may 
be obtained by introduc- 
ing the whole hand into 
the vagina after full dila- 
tation of the cervix, and 
grasping the head with 
the extended fingers, then 
with firm suprapubic 
pressure with the other 
hand attempting to en- 
gage head and fingers together (Fig. 232); or one can simply grasp the head as 
in Fig. 231, and estimate its size by palpation. 

7. Rontgen Cephalometry. — As will be seen by referring to the section on 
Rontgen pelvimetry, recognition of pelvic anomalies is relatively simple. The 
great problem to overcome is the photography of the fetus. If a combined 
shadow of both the head and pelvis could be obtained, much light would be 
thrown upon the relations existing between these structures in individual 
In 1898, Gocht * announced that photography of the fetal skeleton 
* " Lehrbuch d. Rontgen-Untersuchung." 




Fig. 232. — Determining any Disproportion between 
the Fetal Head and the Pelvic Inlet. 



cases. 



THE HYGIENE AND MANAGEMENT OF PREGNANCY. 191 

was impracticable. Varnier, however,* succeeded, after more than three years 
of effort, in obtaining a clear view of the contour of the fetal head in a woman 
seven months pregnant, so that he regards it as practicable to determine the size 
of the head, its position, degree of flexion, and manner of engagement, in the 
latter months of pregnancy. No shadow can be obtained of the spine and 
limbs, however. Varnier 's f complete studies have not yet appeared, and although 
he has demonstrated to me personally in Paris the minute technique of his 
method, I do not feel at liberty to publish it. 



XI. THE HYGIENE AND MANAGEMENT OF PREGNANCY. 

Prophylaxis. — A large proportion of the women who apply to the gynecologist 
for relief of crippled pelvic organs owe their invalid conditions to mismanagement 
or avoidable accidents of the pregnant, parturient, and lying-in states. This 
large class of invalids, who owe their condition to careless and unclean obstetrics, 
can be greatly reduced, if not practically done away with, and the remedy is 
to be found not in the preaching, but in the practice of clean and conservative 
obstetrics. A careful attention to prophylaxis, on the part of the obstetrician, 
is of value not only in anticipating and warding off many of the dangers of 
pregnancy, labor, and the puerperium, but also in preventing many subsequent 
disabilities of a gynecological nature. Nowhere more than here does the old 
maxim, that prevention is better than cure, find truer application. There 
is relatively little that we can do during pregnancy, which will have a direct 
influence in the prevention of subsequent uterine and pelvic trouble. Attention 
to the general health, however, — e. g., the prevention of constipation, the 
proper treatment of coexisting anemia, moderate exercise in the open air, 
suitable clothing, especially the avoidance of constriction about the waist, in 
a word, a good hygiene of pregnancy, — is undoubtedly of prophylactic impor- 
tance in two ways: (i) By providing the patient with healthy blood, one of 
the best of germicides, and thus, perhaps, forestalling or minimizing the effects 
of septic infection; (2) by increasing the muscular and general nutrition, factors 
of undoubted importance in the prevention of subsequent subinvolution of 
the uterus and adnexa. Every pregnant woman should be impressed with 
the importance of placing herself under the care of the physician who is to 
attend her, as soon as she shall become aware of her condition. It would be 
wise to give such a patient, early in gestation, some simple directions, either 
verbal or printed, embracing advice regarding exercise, clothing, diet, care of 
bowels, skin, kidneys, breasts, teeth, and the danger-signals of approaching 
complications. (See Appendix.) There can be little doubt that not only patients 
but their advisers are too prone to consider this a period of invalidism, and 
to forget that it is a physiological process. One of the important results of the 
former view is the neglect of muscular exercise, especially in the higher walks 
of life, where the desire to escape observation, and the fears inspired by false 
ideas, lead to the neglect of even the little exercise — i. e., walking — to which 
the patient is accustomed, and the consequent weakening of the whole muscular 
system. Now, just the opposite should be the case. The strain imposed upon 
the muscular system by the requirements of labor is a severe one, and should 
be forestalled by the cultivation, as far as possible, of muscular strength. In 
the effort, however, to secure a proper hygiene of pregnancy, we should not 

* "Ann. de Gynecol, et d'Obstetrique," April, 1889. 

f Professor Varnier died in 1903. 



192 PHYSIOLOGICAL PREGNANCY. 

forget the danger of overexertion; and this brings us to the consideration of 
one point which I believe to be of especial and direct prophylactic importance. 
I refer to the avoidance of everything which increases intrapelvic pressure 
and resulting pelvic congestion. 

A r o one who has had an extensive obstetric experience can jail to observe that 
a large number of pregnancies are, when carefully studied, really pathological in 
their nature. Witness the frequency of the toxemia of pregnancy as we understand 
the condition to-day, and the probable dependence of most cases of vomiting of 
pregnancy upon this state. (See Part III.) 

Our present knowledge of the pregnant state demands that women at this time 
should be constantly under the observation of a competent physician. 

Pregnancy cannot be treated through the mails or over the telephone. 

It is not enough that a monthly or bi-monthly examination of the urine be made 
for symptoms of hepatic or renal insufficiency , as such urinary analysis often 
fails completely to indicate the presence of toxemia. 

Pregnant women should be frequently seen by their physician, and watched for 
general symptoms of the over-charging of the blood with toxic material — as nausea 
and vomiting, headache, physical and mental lassitude, high arterial tension, 
alterations in character and disposition. 

Thus, and thus only, shall the physician do his whole duty by his patient. 

Exercise. — The pregnant woman is often almost unfitted for exercise in 
the early part of pregnancy, on account of the usual discomfort of "morning 
sickness," and in the last part by her great increase in size, at which latter 
time she generally lies down frequently and is disinclined to any exertion. The 
nausea of the early months often plays a protective role in pregnancy, as it 
demands rest on the part of the patient, who might otherwise overexert herself. 
Nevertheless, a moderate amount of exercise is very beneficial during the period 
of gestation; walking offers the most favorable form, since more violent exercise 
may cause much harm. Carried to the point of slight fatigue every day, exercise, 
especially walking, will put the woman herself, as well as her child, into the 
best physical condition for her approaching labor. If the patient is unable 
to take this kind of exercise, then the passive form obtained in carriage-driving 
will be found next in order of efficiency; but if this causes backache and a 
feeling of weight in the lumbar region it should be forbidden. Jars of every 
kind should be avoided, especially jumping, even from slight elevations, and 
overstretching, such as straining the arms upward in reaching for an object, 
as in hanging pictures, for example. All violent exercise should be forbidden, 
and, as a rule, journeys should be deferred, particularly those by water, on 
account of the dangers due to sea-sickness. If the relaxation of the pelvic 
joints becomes extreme, so that locomotion is interfered with, then even mod- 
erate exercise should be abandoned, and the patient should be advised to make 
no exertion whatever. 

Diet. — An improper or insufficient diet during pregnancy can hardly be con- 
sidered a direct factor in the production of uterine disease. Acting, however, 
in the production of a lower vitality, it is doubtless an indirect factor in the 
production of subinvolution and the evils which follow. There has, as yet, 
been little evidence advanced to show that in cases of normal pregnancy any 
special kind of diet is of importance, nor is it antecedently probable. A mixed 
diet, sufficient in quantity to meet the often increased appetite of the patient, 
is probably the best. Important modifications of diet are, of course, imperative 
in threatened albuminuria, vomiting of pregnancy, and other morbid conditions. 



THE HYGIENE AND MANAGEMENT OF PREGNANCY. 193 

(See Pathological Pregnancy.) The studies of Prochownik and others with 
reference to the prevention of dystocia by a restricted diet, and those of Schenck 
with regard to the determination of sex by an analogous method, are chiefly 
important from the standpoint of pure obstetrics. Usually in early pregnancy 
there are certain digestive disturbances which, with the less active life they 
entail, cause a decrease in desire for food. Mental anxiety, incident to the 
patient's state, also contributes to this condition. In many cases morning sick- 
ness has been avoided, or at least lessened, by giving an early morning breakfast 
to the patient, after which she sleeps for an hour or two before rising. A generous, 
wholesome, and simple diet is demanded by the patient. Meats, vegetables, 
and fruits should be included. Not infrequently the patient longs for certain 
articles of diet that might even have been distasteful before pregnancy. These 
desires should be respected, as they may represent demands by the system for 
certain elements necessary to its peculiar state. These are not perversions 
of appetite, which have been noted before. By the fourth month the gastric 
disorders disappear, as a rule, and appetite returns. It is well, during the last 
of gestation, for the patient to take several extra lunches daily, and on account 
of the encroachment of the enlarging uterus on the gastric space, the amount 
of food taken at one time should be smaller, but the intervals between meals 
should be shorter. 

Drink. — The drink should be water, milk, or chocolate; tea and coffee may 
be taken in moderation, but should not be strong. Alcoholic beverages should 
be avoided, for the pregnant woman is especially prone to contract the alcoholic 
habit. 

Bowels. — The bowels should be carefully looked after, and constipation is 
to be especially avoided. Plenty of water should be taken and the diet should 
look toward the alleviation of constipation. Coarse cereals, bread, fruit, etc., 
encourage free movements. Enemata or mild laxatives may be added to the 
regime. Glycerin, soap, gluten, and cocoa-butter suppositories are useful; 
one or two teaspoonfuls of aromatic cascara at bedtime ; tasteless fluid extract 
of cascara and fluid extract of licorice each a half-teaspoonful at bedtime; 
tablet triturates with varying combinations of aloin, cascarin, belladonna, and 
strychnine. The habitual use of suppositories and enemata should be avoided, 
as well as the sulphate of soda, mineral waters, or, in fact, the constant use of 
any drug, as our object should be to secure proper action of the bowels by 
attention to the diet and the free use of water. Most pregnant women are 
benefited by an occasional dose of a mercurial at bedtime, followed by a saline 
or sulphur water in the morning. (Compare Constipation, under "Pathological 
Pregnancy.") 

Fresh Air. — Plenty of outdoor air is essential to the patient. The gravid 
woman is eliminating an increased amount of carbonic acid, as she is breathing 
for two. Crowded rooms should be sedulously avoided, and all impure air, 
sewer-gas, etc., excluded. There must be thorough ventilation of the rooms occu- 
pied both by night and day. Frequent rests in the recumbent position are essen- 
tial. From eight to ten hours out of every twenty-four should be devoted to 
sleep. Especially should those times corresponding to the menstrual epoch be 
guarded from any untoward conditions. 

Care of the Skin. — The skin should play its full part as an eliminating organ, 
especially in the last part of pregnancy, as the kidneys must be relieved as 
far as possible of extra work. Bathing should be continued according to the 
patient's habits before pregnancy. Reaction may be secured by friction with 
a coarse towel. Hot and cold baths, however, or any shock, — for example, 
13 



194 



PHYSIOLOGICAL PREGNANCY. 



that incident to sea-bathing, — should be avoided. Tepid vaginal douches are 
often a source of great comfort. 

Clothing. — Clothing should be well adapted to the condition. Corsets are 
to be laid aside; low-heeled shoes are to be preferred; it is well to suspend the 

weight of the garments from the shoulder-straps. 
The clothes should weigh as little as possible and 
be loosely fitted. Circular garters ought to be 
replaced by side supporters. It is well to recom- 
mend warm drawers as soon as the enlarging 
abdomen lifts the skirts from the thighs. If the 
abdomen be very lax and pendulous, a suitable 
binder may well be applied for support. It 
should aim to lift the weight from below and 
exert no pressure. One of the best abdominal 
supporters is a French maternity corset (Figs. 
233 and 234), which combines support of the 
lower abdomen with that of the breasts. I had 
this corset imported several years ago, and have 
used it in my practice, with much satisfaction to 
my patients.* 

Leucorrhea. — In the case of leucorrheal dis- 
charge, vaginal douches may be necessary, and 
bathing and care of the external genitals are ab- 
solutely demanded for the comfort of the mother. 
Local treatment, if demanded, can be applied 
without harm, with proper precautions. 

A suppository of hydrochlorate of hydras- 
tinine gr. i, borate of zinc gr. i, extract of bella- 
donna gr. J, and boroglyceride 5ss, may be in- 
troduced into the vagina at bedtime after a 
cleansing douche of a saline solution. Or in sub- 
acute and chronic cases with profuse discharge , 
after a vaginal douche at bedtime, a suppository 
of extract of belladonna gr. ss, tannic acid grs. 
v, and boroglyceride 5ss, may be used. Useful 
vaginal douches are those of alum, a tablespoon- 
ful to a quart of water; of a solution of subacetate 
of lead and laudanum, each a dessertspoonful to 
a quart of water, after thorough cleansing with a 
saline douche; of acetate of lead and sulphate 
of zinc, each half a teaspoonful in one or two 
quarts of water. Nitrate of silver, thirty grains 
to the ounce of water, may be carefully applied 
to the vaginal mucous membrane through a 
cylindrical speculum. 

Breasts. — There must be no pressure on the 
mammary glands, and they must be warmly covered. The nipples particularly 
must be kept scrupulously clean. The physician should make an examination 
of these organs a month before labor, when any abnormalities, such as abrasions, 
fissures, milk scabs, etc., can be treated. If the nipples are retracted, they may 

* This maternity corset is now made in this country for me by Mrs. Leighton, 3 East 
41st Street, New York city. 




Fig. 233. — An Improved Ma- 
ternity Corset for Sup- 
port of the Lower Abdomen 
and Breasts in the Latter 
Weeks of Gestation. An- 
terior View. — {From a pho- 
tograph taken at the Emergency 
Hospital.) 



THE HYGIENE AND MANAGEMENT OF PREGNANCY. 195 



be drawn out gently every day by the patient herself, but great care must be 
observed in this process, on account of the pernicious results which might follow 
the uterine contractions that may be evoked by this manipulation. Some believe 
in the daily exposure of the nipples to the air, in order to render more active the 
epidermic secretion. (For breast supporters, see 
Pathological Puerperium, Part VII.) 

Mental Condition. — Mental depression and 
excitement should be guarded against. In cer- 
tain cases the patient preserves a cheerful tem- 
per, but often in pregnancy increased emotional 
susceptibility exists, with depression and irrita- 
bility that are apparently entirely beyond her 
control. Events which in the non-pregnant 
state would have no effect, cause excitement 
and annoyance. At times there are perversions 
of the special senses involving no structural 
nerve changes. Anxiety should be quieted, 
kind assurances and encouragement should not 
be spared. The patient should be guarded from 
all petty worries and troubles, as well as from 
shocks or surprises. She should avoid large 
gatherings, such as the church or the theater, on 
account of the mental impressions to which 
they subject her. Judicious amusement should 
,be provided, and she should be surrounded by 
cheerful and agreeable companions, while her 
mind should be occupied by some pleasant and 
congenial occupation. She should be shielded 
with a gentle and protective care, and her hus- 
band should accept his full share of responsibility 
by co-operating with her, in order to secure the 
tranquillity and repose of mind so essential for 
the well-being of both the mother and the child. 
The influence, moral, mental, physical, of the 
mother on the fetus in utero is a subject so vast 
and complex that its depths have never yet been 
sounded. Great allowance should be made for 
the whims and irritability of the pregnant 
woman, as she is often not responsible for her 
altered temper. Many changes in her are prob- 
ably due to the alterations, both quantitative 
and qualitative, in her blood at this time, as 
well as to the changes taking place in her sexual 
organs. So she should be humored and shielded, 
and her idiosyncrasies should be gently over- 
looked. 

Examination of the Urine. — From the third 
to the seventh month, monthly examinations of 

the urine should be made; from the seventh to the ninth month, every two weeks, 
and then once a week till labor begins. The patient should be warned to make 
an immediate report of any decrease in the amount of urine excreted in the 
twenty-four hours. The examination should take account of the twenty-four 




Fig. 234. — An Improved Ma- 
ternity Corset for Support 
of the Lower Abdomen and 
Breasts in the Latter 
Weeks of Gestation. Pos- 
terior View. — {From a photo- 
graph taken at the Emergency 
Hospital.) 



196 PHYSIOLOGICAL PREGNANCY. 

hours' amount, the specific gravity, the quantity of urea and its variation, and 
the presence of albumin and casts. Through this constant watch for symp- 
toms of toxemia many cases of eclampsia may be avoided. 

Sexual Intercourse. — The subject of marital intercourse during pregnancy 
has received much attention. Many and diverse opinions have been expressed, 
but it is generally considered that during the first months of pregnancy, and at 
the last, sexual intercourse should be forbidden. To most pregnant women it 
is distasteful, although in others the sexual appetite is increased. It often causes 
great pelvic discomfort. It should in any case be forbidden at those times 
which correspond with the menstrual epochs, as then pelvic congestion and a 
special tendency to abortion exist. Sexual intercourse is held to be one of the 
most influential factors in producing abortion and systemic disturbances. 

The possibility of infection of the uterus during coitus from germs beneath 
the foreskin cannot be denied. This is especially liable to occur in a case of 
placenta prasvia. 



PART THREE. 

Pathological Pregnancy* 



I. DISEASES OF THE DECIDU^E. 1. Acute Infectious or Exanthematous 
Deciduitis. 2. Acute Hemorrhagic Deciduitis. 3. Acute Purulent De= 
ciduitis. 4. Chronic Catarrhal Deciduitis, Endometritis Gravidarum 
Catarrhal is. Endometritis Deciduae Catarrhalis. 5. Chronic Diffuse Hyper- 
plastic Deciduitis, Endometritis Deciduae Chronica Diffusa, Endometritis 
Gravidarum Hyperplastica. 6. Chronic Tuberous or Polypoid Deciduitis. 
7. Chronic Cystic Deciduitis. 8. Apoplexy of the Decidua. 9. Atrophy 
of the Decidua. 10. Decitiuoma. 11. Deciduoma Malignum. 

II. DISEASES OF THE CHORION. 1. Cystic Degeneration of the Chorionic 
Villi; Hydatidiform or Vesicular Mole; Myxoma Chorii Multiplex. 2. 
Fibromyxomatous Degeneration of the Chorion. 3. Chronic Choriitis. 

III. ANOMALIES OF THE AMNION AND LIQUOR AMNII. 1. Plastic Exu- 

dation, Amniotitis. 2. Abnormal Tenuity. 3. Cysts and Dermoids. 4. 
Premature Rupture, Amniotic Hydrorrhea. 5. Anomalies in Color and 
Composition of Liquor Amnii. 6. Oligohydramnios. 7. Hydramnios. 

IV. ANOMALIES AND DISEASES OF THE PLACENTA. 1. Anomalies.— 

(1) Size: (a) Atrophy; (b) Hypertrophy; (c) Placenta Membranacea. (2) 
Form. (3) Number. (4) Relation. (5) Insertion : Placenta Praevia. 2. 
Injuries. — Premature Detachment. Accidental Hemorrhage. 3. Stasis 
and CEdema. 4. Interstitial Hemorrhage. — Apoplexy. Infarction. 
Thrombosis. 5. Placentitis. — (1) Acute Septic, (2) Gonorrheal, (3) Eman- 
uel's Disease. (4) Specific; (5) Chronic Interstitial and (6) Albuminuric. 6. 
Infectious Granulomata. — Tuberculous and Syphilitic. 7. Secondary Meta= 
morphoses. — (1) Progressive. Hyperplastic and Sclerotic. Adherent 
Placenta. (2) Regressive. Results of Fetal Death. White Infarcts. 
Cystic, Calcareous, Fatty, and Miscellaneous Degenerations. 8. Tu- 
mors. — Placentomata. Polypi. 

V. ANOMALIES OF THE UMBILICAL CORD. 1. Length. 2. Thickness. 
3. Insertion. 4. Coils. 5. Knots. 6. Tangling. 7. Torsion. 8. Stenosis 
of the Vessels. 9. Cysts. 10. Calcareous Deposits. 11. Hernia. 12. Syph- 
ilis. 13. Obstruction of the Vessels. 14. Dilatation of the Umbilical Vein. 

15. Hypertrophy of the Valves. 16. Congenital Tumors. 

VI. DEFORMITIES AND MONSTROSITIES OF THE FETUS. 

VII. ANTENATAL DISEASES OF THE FETUS. 1. Infectious Diseases. 2. 
Acute Poisoning. 3. Chronic Poisoning. 4. Dyscrasic Conditions. 5. 
Cardiac Diseases. 6. Diseases of the Alimentary Tract. 7. Diseases of 
the Nervous System. 8. Diseases of the Urogenital Apparatus. 9. Skin 
Diseases. 10. Bone Disease. 11. Traumatisms. 12. Neoplasms. 13. 
General (Edema. 14. Maternal Traumatisms. 15. Maternal Uterine Dis- 
ease Affecting the Fetus. 16. Fever in the Mother Affecting the Fetus. 
17. Death of the Mother Affecting the Fetus. 

VIII. DEATH OF THE FETUS. 1. Maceration. 2. Mummification. 3. Ab- 
sorption. 4. Putrefaction. 5. Saponification. 6. Calcification. 

IX. DISEASES OF THE GENITAL ORGANS. 1. Anteflexion and Anteversion. 
2. Retroflexion, Retroversion, and Incarceration. 3. Lateroflexion and 
Latero version. 4. Prolapse of the Pregnant Uterus. 5. Torsion. 6. 
Hernial Protrusion of the Pregnant Uterus. 7. Periuterine Inflammation 
and Adhesion. 8. Rheumatism of the Uterine Muscle. 9. Metritis. 10. 
New Growths of the Uterus. 11. Spontaneous Rupture. 12. Malforma- 
tions. 13. Leucorrhea. 14. Cystic Vaginitis. 15. Specific Vaginitis. 

16. Prolapse of the Vagina. 17. Pruritus Vulvae. 18. Varicosities of 



Vagina and Vulva. 19. Vegetations. 20. (Edema of the Vulva. 21. 
Eczema of the Nipple. 22. Mammary Abscesses. 23. Hemorrhage 
from the Genitals during Pregnancy. 

X. THE TOXEMIA OF PREGNANCY. AUTO=TOXEMIA OF PREG= 
NANCY. HEPATIC INSUFFICIENCY. PREGNANCY LIVER. PRE= 
ECLAMPTIC STATE. 1. Toxemia of Pregnancy. 2. Nausea and 
Vomiting. 3. Icterus. 4. Convulsions and Coma. 5. Eclampsia. 

XI. DISEASES OF THE URINARY TRACT. 1. Passive Congestion of the 
Kidney. 2. Acute Nephritis. 3. Chronic Nephritis. 4. Floating Kidney ; 
Tumors of the Kidney. 5. Pyelonephritis. 6. Hydronephrosis. 7. 
Renal Calculi. 8. Renal Insufficiency and Toxemia. 9. Vesical Irritation. 
10. Cystitis. 11. Incontinence of Urine. 12. Urinary Retention. 13. 
Vesical Hemorrhoids. 14. Vesical Calculi. 15. Cystocele. 16. Vesical 
Neoplasms and Traumatism. 17. Albuminuria. 18. Polyuria. 19. 
Peptonuria. 20. Hematuria. 21. Glycosuria. 22. Lipuria and Chyluria. 
23. Acetonuria. 24. Urinary Sediments of Pregnancy. 

XII. DISEASES OF THE ALIMENTARY TRACT. 1. Gingivitis. 2. Dental 
Caries. 3. Oral Sepsis. 4. Salivation or Ptyalism. 5. Anorexia. 6. 
Nausea and Vomiting. 7. Persistent Vomiting, Hyperemesis Gravis 
darum. 8. Malacia, Longings. 9. Gastric and Intestinal Indigestion. 
10. Consumption. 11. Diarrhea. 12. Hemorrhoids. 13. Jaundice, 
Icterus Gravidarum. 

XIII. DISEASES OF THE CIRCULATORY SYSTEM. 1. Acute Endocarditis. 
2. Chronic Endocarditis. 3. Affections of the Heart Muscle. 4. 
Graves's Disease. 5. Varicosities. 6. Aneurysm. 7. Palpitation. 8. 
Syncope. 9. Hydremia. 10. Pernicious Anemia. 11. Exophthalmic 
Goiter. 

XIV. DISEASES OF THE RESPIRATORY SYSTEM. 1. Hyperosmia. 2. 
Bronchitis. 3. Pneumonia. 4. Emphysema. 5. Pleurisy. 6. Hemop= 
tysis. 7. Pulmonary Tuberculosis. 8. Acute Miliary Tuberculosis. 
9. Dyspnea of Pregnancy. 10. Neuroses and Spasmodic Cough. 11. 
Asthma. 

XV. DISEASES OF THE NERVOUS SYSTEM. 1. Cerebral Disease. 2. Ges= 
tational Melancholia, Mania, and Dementia. 3. Vertigo and Syncope. 
4. Insomnia. 5. Gestational Paralysis. 6. Gestational Neuralgias. 7. 
Neuroses. 

XVI. INFECTIOUS DISEASES. 1. Variola. 2. Scarlatina. 3. Measles. 4. 
Typhoid. 5. Typhus. 6. Erysipelas. 7. Malaria. 8. Pneumonia. 9. 
Syphilis. 

XVII. SKIN DISEASES. 1. Pruritus. 2. Pigmentation. 3. Herpes Gestationis. 
4. Impetigo Herpetiformis. 5. Alopecia. 

XVIII. DISEASES OF THE OSSEOUS SYSTEM. I. Relaxation of the Pelvic 
Joints. 2. Inflammation of the Joints. 3. Osteomalacia. 4. Rachitis. 

XIX. THE PREMATURE INTERRUPTION OF PREGNANCY. 

XX. ECTOPIC GESTATION. 

XXI. PREGNANCY IN ONE HORN OF A UTERUS UNICORNIS OR BI= 
CORNIS. 

XXII. MISSED LABOR. 

XXIII. SUDDEN DEATH DURING PREGNANCY. 

XXIV. INJURIES AND OPERATIONS UPON PREGNANT WOMEN. 

XXV. PREGNANCY AFTER OPERATIONS INVOLVING THE GENITALS. 
Pregnancy after Ventro=fixation and Ventro=suspension. (See Patho= 
logical Labor, page 657.) 

XXVI. THE FEVER OF PREGNANCY. 

XXVII. THE METRORRHAGIA OF PREGNANCY. 



Pathological or abnormal pregnancy is one in which some departure from a 
physiological pregnancy occurs in mother, ovum, embryo, or fetus. Although 
the vast majority of pregnancies are normal, still it must be remembered that 
in all classes of mankind the departures from the normal standard in ances- 
tors and parents, with their accompanying physical imperfections, latent or 
obscure though they may be, will show themselves in even more pronounced 
and dangerous forms in the pregnant woman and the fetus in titer o. The 
influences upon the present and subsequent generations of years of improper 
hygienic environment and nutrition, with their resulting faulty development 
of muscle and bone, and reflex neuroses must never be lost sight of in the 
examination of pregnancy. 



I. DISEASES OF THE DECIDU/E. 

I. Acute Infectious or Exanthematous Deciduitis. 2. Acute Hemorrhagic Deciduitis. 3. 
Acute Purulent Deciduitis. 4. Chronic Catarrhal Deciduitis, Endometritis Gravidarum 
Catarrhalis, Endometritis Deciduce Catarrhalis. 5. Chronic Diffuse Hyperplastic 
Deciduitis, Endometritis Deciduce Chronica Diffusa, Endometritis Gravidarum Hyper- 
plastica. 6. Chronic Tuberous or Polypoid Deciduitis. 7. Chronic Cystic Deciduitis. 
8. Apoplexy of the Decidua. g. Atrophy of the Deciduce. 10. Deciduoma. 11. De- 
ciduoma Malignum. 

Introduction. — The decidua is the transformed endometrium, and it is sub- 
ject to any of the diseases that may attack the non-gravid uterine mucous 
membrane; only in the case of pregnancy these affections are apt to assume 
a severe grade, owing to the great hypertrophy of the tissue concerned. The 
results are apt, also, to be more serious, on account of the relation to the fetus. 
Endometritis, so called, is generally not inflammatory, so the term, as often 
applied, is a misnomer. These diseases are of several forms. There may be 
inflammation, which in turn may be either acute or chronic. Acute inflamma- 
tion may occur in the course of cholera or other infectious diseases, but espe- 
cially with the exanthems. It may result from the unsuccessful attempt to 
produce abortion, or even sometimes from external traumatism. Generally 
it is the extension of an old inflammatory process, which has existed in the 
non-pregnant uterus. Thus it will be seen that although inflammation of the 
decidua may be antedated by endometritis of the non-gravid uterus, this is 
not always the case. Following endometritis may be frequent abortions, ab- 
normal positions of the ovum, inflammatory conditions of the placenta and 
fetal membranes, thickening and retention of the decidua, and arrested 
development of the fetus. Other causes of primary decidual endometritis 
may be syphilis, gonorrhea, infectious diseases, nephritis, and infection fol- 
lowing long-continued labor. 

1. Acute Infectious or Exanthematous Deciduitis. — As its name implies, this 
is generally a result of the acute infectious diseases, although it may be an 
extension of an inflammation from the endometrium before pregnancy. Ahlfeld 

199 



200 PATHOLOGICAL PREGNANCY. 

declares that the cervix is nearly always infected first, and this can be clearly seen 
if the decidua serotina lies near the cervix, as in placenta praevia. Of great 
interest are the eleven cases of Klotz, which show the effect of measles on preg- 
nancy. Xine of these suffered from abortion, at a time which seemed to show a 
direct connection between the expulsive efforts of the uterus and the breaking- 
out of the eruption on the skin. Klotz believes that the uterine contractions 
are caused by the irritation of the exanthem as it occurs on the mucous mem- 
brane of the uterus. This disturbance is analogous to the photophobia, coryza, 
bronchitis, and vesical tenesmus, which are the expression of the effect of the 
same irritating cause on the other mucous membranes. The same explanation 
would probably hold good for abortions occurring in any of the eruptive fevers. 
This condition consists in active inflammatory changes, which may vary from 
small foci to an inflammation of the whole decidua. Bacteriologic examinations 
have been for the most part negative, but Donat and Leopold have reported 
micro-organisms, though their descriptions are scanty. Yeit and Emanuel 
have described a bacterium which resembles the colon bacillus. Malowsky and 
Xeumann have noted the presence of gonococci in the affected tissues. The 
gross and microscopic appearance varies much according to the extent of the 
disease. 

2. Acute Hemorrhagic Deciduitis. — This condition has been found in two 
cases associated with cholera (Slavjansky). The decidua was dark purple in 
color, and thickened, while throughout its extent were many extravasations 
of blood. It is logical to suppose that the other infectious diseases could cause 
the same condition. There is hardly another tissue in the human body so easily 
destroyed through the tearing of its blood-vessels as the pregnant decidua. 
Any small injury is sufficient to harm these structures. In the deciduae of 
abortion may often be found old and fresh extravasations of blood between the 
villi. In one variety tuberosities form, much like those seen in the tuberous 
decidua. Through organization of the extravasations in the intervillous 
spaces, placental nourishment is shut off from the fetus, which therefore perishes. 
If the extravasation continues after the death of the fetus, there is finally formed 
what is known as a fleshy mole. This structure conforms to the shape of the 
uterine cavity, and consists of various layers of blood of different hemorrhages, 
held together by means of the atrophied villi. In the center of this mass we 
usually find the empty amniotic cavity, but at times the macerated fetus is 
present. (Compare Pathology of Interrupted Pregnancy.) 

3. Acute Purulent Deciduitis. — This condition is very rare. The case de- 
scribed by Donat shows the state of the structures concerned. This patient 
expelled at term a placenta which was surrounded by a margin of decidual 
tissue infiltrated with pus. Between the amnion and chorion, which were both 
thickened and opaque, was a mass of purulent liquid. This condition probably 
resulted from an unsuccessful abortion attempted by the woman herself. Various 
explanations have been offered to clear up the nature of the case. Donat him- 
self thinks that the pus made its way from the decidua through the chorion, 
collecting between the latter membrane and the amnion. Careful macroscopic 
and microscopic examinations were made, dispelling all doubt about the case. 
Hirst suggests that the pus might have been originally expressed from a dis- 
tended tube. Thence it may have forced its way through the ovular decidua, 
or. if earlier in pregnancy, through the layers of the membranes. This last 
theory seems quite plausible, in consideration of the recent work done on hydror- 
rhcea ovarialis intermittens, in which affection there is a periodic discharge 
from the tube into the uterus. 



DISEASES OF THE DECIDUJE. 201 

4. Chronic Catarrhal Deciduitis; Endometritis Gravidarum Catarrhalis; En- 
dometritis Deciduae Catarrhalis; Hydrorrhoea Gravidarum. — Definition. — This is 
a chronic inflammation of the decidual endometrium, probably arising from 
some obscure morbid condition of the mucous membrane. 

Pathology. — Many theories have been advanced to explain this rare condi- 
tion. It may arise from a hypertrophy of the glands, whose openings are not 
obliterated; and, as a result of this state of chronic glandular inflammation, a 
clear viscid liquid is poured out between the decidua and chorion, whence it 
makes its escape to the os uteri. The secretion varies greatly in quantity; in 
one reported case, from one-half to three-quarters of a liter was lost each 
time. Some believe that the secretion comes from the bursting of a cyst which 
is formed between the ovum and the uterine walls; others, that it is a transu- 
dation of the liquor amnii through the membranes. Another suggestion is that 
the liquid escapes from an opening in the membranes at a distance from the 
os uteri ; still another, that the liquid comes from a sac between the amnion and 
chorion. In these last cases there may be only one gush of the liquid contents. 
But if the discharge is a continuous one, or repeated intermittently, neither of 
these theories will hold good. Authorities differ in regard to the time of ges- 
tation at which this affection supervenes. It would seem most logical to believe 
that it is in the first part of pregnancy, before the reflexa joins the vera; if, 
however, this union does not take place, the discharge may continue through 
pregnancy. 

Symptoms. — The fluid, which is of a pale yellowish color and transparent, 
may escape from the vagina by dribbling, or there may be one sudden gush. 
It may escape from time to time for weeks, and in such quantity as to soak 
the clothing of the patient. If the discharge takes place at night when the 
patient is lying perfectly quiet, the cause is then doubtless contraction of the 
uterus. 

Diagnosis. — The chief point of interest in the disease is its liability to 
cause errors in diagnosis, for if a physician is called to a case, and is told 
that there has been an escape of waters, he is apt to think that the mem- 
branes have been ruptured. In hydrorrhea there are no pains, the cervix is 
not dilated, and ballottement can be obtained. If after this exhibition of 
watery discharge pregnancy continues as before, the diagnosis of hydrorrhea 
may be established. The patient is generally alarmed at the symptoms, but 
her fears are groundless, for pregnancy often continues to term with no untoward 
phenomena. 

Differential Diagnosis. — Hydrorrhoea gravidarum is differentiated from hy- 
dramnios by the character of the secretion, by the absence of vernix caseosa 
or lanugo, and by the fact that premature labor does not occur, or at least 
occurs only after a comparatively long period. It is distinguished from incon- 
tinence of urine also by the nature of the secretion, and by the absence of urea 
and of acid reaction. Endotrachelitis and colpitis are excluded by inspection, 
and by the absence of pus. The fact should be noted, however, that pus may 
occur if the disease is accompanied by an endometritis. 

Prognosis. — In general, with proper treatment, the prognosis is good for 
both mother and child, as the pregnancy is not compromised by the dis- 
ease. The child should be born at term and in good condition. If other 
causes of abortion are operative, the gestation may of course be interrupted. 
When the discharge is continuous and of a dark hue, the case may not go on 
to term. 

Treatment. — The management is comprised in the prophylaxis of abortion. 



202 



PATHOLOGICAL PREGNANCY. 




The woman should be kept recumbent, even in cases of moderate degree. 

Opiates should be administered if uterine contractions are present. 

5. Chronic Diffuse Hyperplastic De- 
ciduitis; Endometritis Deciduae Chronica 
Diffusa; Endometritis Gravidarum Hyper- 
plastica. — Definition. — Instead of the atro- 
phy of the uterine mucous membrane that 
normally takes place in the latter part of 
pregnancy, the condition of hyperplasia 
that existed in the first part continues to 
increase (Fig. 235). 

Pathology. — This steady progression, 
which affects both layers of the decidua, 
results in a membrane I or -J- inch (3 or 4 
mm.) in thickness. The cells increase in size, 
and have larger, more vesicular nuclei. The 
tissue looks like that of a sarcoma, and has 
been described as such. If the disease makes 
rapid strides, abortion will generally occur 
as a result of hemorrhages into the mucous 
membrane, which separate it from the wall 
of the uterus. Or it may occur from the 
death of the fetus, whose nourishment has 
all been diverted to the increase of the de- 
cidua. The embryo may be absorbed, and 
the decidual membranes afterward dis- 
charged as an empty sac with very thick 
walls, in which case it constitutes one 
variety of the fleshy moles. (See Abortion.) 
Or the embryo may be destroyed by hemor- 
rhages into the abnormally developed de- 
cidua, the blood forcing its way through all 
obstructions into the cavity of the ovum. 
In this condition only microscopic examina- 
tion will reveal the true character of the 
tissues. Besides the hypertrophy of the 
cells already mentioned, the blood-sinuses 
are enlarged. There is an abundant plastic 
exudate, which, unable to form connective 
tissue, becomes amorphous and fatty. 
New-formed muscle-fibers have been seen 
in the hypertrophic tissues. The etiology 
of this affection is generally an antecedent 
morbid condition of the mucous mem- 
brane, which the presence of the fecun- 
dated ovum excites to abnormal prolifera- 
tive activity. The morbid condition is 
actually a chronic endometritis, either 
simple, or syphilitic or gonorrheal. Simi- 
larly, the death of the embryo, or some 

disease of the latter, may excite the previously healthy mucous membrane to 

overgrowth. 



Fig. 235. — Decidual Endometritis. 
— (Schaeffer.) 1, Dilated gland- 
follicles with desquamated epi- 
thelium; in hypersecretion these 
glands discharge their contents, as 
at 9 and 10, between the decidua 
reflexa and the decidua vera into 
the free lumen of the uterus — hy- 
drorrhea gravidarum; 2, chorionic 
villi embedded in partially disin- 
tegrated decidual tissue (3) ; 4, 
intact chorionic villi lying in the 
free intervillous spaces (filled with 
maternal serum or blood), either 
in close apposition or adherent to 
the decidua vera ; 5 , small vascular 
villi branching from a large attach- 
ment-villus (6), the latter gradu- 
ally merges into decidual tissue; 7, 
capillary vessels in the inflamed 
interstitial portion; 8, glandular 
endometritis; 9, interstitial endo- 
metritis with areas of round-celled 
and leukocytic infiltration; 10, de- 
cidua reflexa merging into decidua 
vera; 1 1, a gland with intact cylin- 
drical epithelium from that part of 
the uterine cavity which is not 
filled with the ovum, although 
forming a part of the decidua 
vera; 12, hypertrophied decidual 
tissue forming polypoid or bridge- 
like excrescences, and showing a 
telangiectatic tendency (7). 



DISEASES OF THE DECIDUA. 



203 



Prognosis. — The results of this disease are generally injurious to both 
mother and child. The danger to the mother lies in the frequent retention 
in titer o of remnants of the placenta, which are not expelled with the rest of 




Fig. 236. — Decidua Tuberosa from an Abortion. — (Ahljeld.) 



the ovum. Frequently the decidua over the placental site is retained, giving 
rise to hemorrhages or septicemia. This condition has been described under 
various names by different authorities. 

6. Chronic Tuberous or Polypoid Deciduitis. — This is the most important 

disease of the decidua, and was first 
described by Virchow, who thought it 
syphilitic in origin, since his case ex- 
hibited a syphilitic history (Figs. 236, 
237, 238, and 239). Later work, how- 




Fig. 



237. — Decidua Tuberosa Poly 
posa.— (Ahlfeld.) 




Fig. 238. — Polypoid Degeneration of the 
Decidua Vera. The upper figure is a 
section of one of the polypoid growths 
enlarged, showing blood-vessels at a and 
decidual cells at b. — (Veit.) 



ever, shows no evidence that the disease is due to syphilis, and no assignable 
cause has thus far been discovered. 

Pathology.— This is a hyperplastic affection, and corresponds to hyperplasia 
in the non-pregnant condition, so that the etiology of this form of deciduitis 



204 



PATHOLOGICAL PREGNANCY. 




must be traced to a pre-existing chronic endometritis. The disease belongs 
to early ova, and quite often the chorionic villi are seen to have undergone 
myxomatous degeneration. Schroeder states that in all the cases so far de- 
scribed, abortion has occurred between the 
end of the second month and the beginning 
of the fourth. Ahlfeld says that this con- 
dition is frequently seen in aborted ova. 
The internal surface of the decidua is 
studded with villus-like projections, which 
measure half an inch (1.25 cm.) or more in 
height (Fig. 238). They are polypoid no- 
dules or cones, very vascular, and possess 
a smooth surface. Between these nodes 
may be seen the openings of the glands, 
which do not appear at all upon the pro- 
jections. The entire membrane is much 
thickened, and consists of proliferated con- 
nective tissue, and hypertrophy of the de- 
cidual cells, with enlargement of the nuclei. 
Although the surface is by some described 
as smooth, others characterize it as rough 
and covered with coagulated blood. Bulius, 
of Freiburg, has done much work in this 
field. Sections show decidual cells with a 
little glandular tissue. The fibrous bundles 
of connective tissue constrict the gland open- 
ings and blood-vessels. Yet, in spite of this, 
the entire decidua is extremely vascular. 

7. Chronic Cystic Deciduitis, or Endometritis Deciduae Cystica (Fig. 240). — 
This affection is rare, but has been observed by Hegar and Breus. It resem- 
bles the last form, endometritis polyposa, 

except that the fibrous elevations are not 
masses of decidual cells, but consist of cystic 
gland cavities which contain liquid. They are 
retention-cysts, formed by occlusion of the 
glands of the uterine ducts. This condition is 
found only in very young ova. It might 
occur in the first stages of chronic hyperplas- 
tic decidual endometritis, in which the advanc- 
ing disease destroys and later obliterates the 
glands. About the retention-cysts the connec- 
tive tissue is hypertrophied, and embryonal 
elements are also found, together with an 
increase in decidual cells. 

Treatment of Decidual Inflammations. — In 
pregnancy the treatment of these chronic forms 
of endometritis is impossible, the only resource 
being to use prophylaxis, by treating the ante- 
cedent chronic endometritis that is almost in- 
variably present. 

8. Apoplexy of the Decidua. — We have alluded to this subject under hemor- 

* "Arch, fur Gyn.," Bd. xix, S. 486. 



Fig. 239. — Tuberous Subchorial 
Hematomata of the Decidua. — 
(Walther.) 




Fig. 240. — Degeneration of the 
Decidua Vera. — (Breus *) 



DISEASES OF THE DECIDUJE. 



205 



rhagic endometritis. The great vascularity of the decidual and the delicacy 
of the walls of the vessels predispose these tissues, under the influence of mild 
traumatism, to effusion of blood, with resulting abortion. Apoplexy of the 
decidua occurs most frequently during the first two months of pregnancy. 
The blood collects both within and between the membranes. As it flows into 
the uterine glands tufted prominences often form, the arrangement of which 
may be either discrete or uniformly disseminated. The effusion of blood may 
extend through the entire thickness of the decidual (Fig. 241). 

If abortion occurs directly after the effusion of blood, the whole mass dis- 
charged is known as a blood or sanguineous mole {mola sanguined). But if this 
expulsion occur at a later period, there is time for the organization of blood- 
clot, which gives a curious raw-beef appearance to the mass, which is then called 
a carneous or "fleshy" mole {mola camosa). (See Abortion.) If a deposition of 
lime salts take place in the clots, as it rarely does, there is formed a calcareous 





Fig. 241. — Fleshy Mole (Mola Carxosa.) 
—{Ahlfeld.) 



Fig 



242.- 



-Atrophy of TH] 
Vera.— {Ahlfeld.) 



Decidua 



or "stone" mole. Pregnancy coming to an end in this manner is called a false 
or molar pregnancy, and the product is known as a "blighted" ovum. 

The etiology of apoplexy of the decidua consists in traumatisms of various 
kinds: injuries, blows, repeated congestions from too frequent coitus; also 
Bright's disease, the deciduae sharing in the general tendency to congestion 
characteristic of this disease. 

The treatment is simply that of abortion. 

9. Atrophy of the Decidua. — In rare instances the deciduae atrophy instead 
of undergoing hypertrophy and hyperplasia (Fig. 242). Hegar, Matthews Duncan, 
Spiegelberg, and Priestley have described this condition. The uterine, ovular, 
or placental decidua may participate in this change either singly or together. 
If the uterine mucosa is affected, the ovum does not find a sufficient resting 
place in the uterine fundus. It stays in its normal site until it becomes too 
heavy for the decidual attachments. These it gradually pulls into a long, 
slender pedicle, which lodges in the cervix. It increases in size till it causes 
reflex contractions of the cervix, being in this manner expelled from the uterus. 



206 PATHOLOGICAL PREGNANCY 

This is the cervical pregnancy of Rokitansky. If the ovular decidua is affected, 
there is lacking the outermost membrane of the ovum, which consequently 
may rupture and its contents be expelled from the uterus. 

io. Deciduoma. — Neoplasms of the decidua are very rare. Two varieties 
have been described, one of which is non-malignant and the other malignant. 
Deciduoma consists of the remains of decidua which have undergone hyper- 
plasia. The chief symptoms are hemorrhage, a leucorrheal discharge which 
is fetid and profuse, with now and then fragments of decidual tissue. There 
are elevated temperature, chilly sensations, and prostration, showing a certain 
amount of toxemic disturbance. There is only an insecure attachment between 
the tumor and the uterine wall. The growth should be thoroughly removed 
by the curette. Quinine, ergot, and stimulants are indicated internally. 

n. Deciduoma Malign um. — Historical. — 

Before 1888 it was known that in some instances after the occurrence of abortion, full- 
term delivery, and particularly vesicular mole, a few patients died of a disease which was 
rapidly fatal, and which showed at autopsy sarcoma-like masses in the uterus, with meta- 
static deposits in various parts of the body. Chiari * has described three cases of "carci- 
noma" of the fundus, and Maier,f in the same year, cited two cases of tumor of the uterus 
of a decidual character. In addition to these, a few similar experiences have been recorded 
by other observers. In 1888, Sanger J demonstrated the disease which we now know as 
deciduoma malignum, and later, in 1893, he investigated its histogenetic characteristics. 
In his later contributions he changed his first designation of deciduoma malignum to 
sarcoma deciduo-cellulare. However, the earlier term is satisfactory for ordinary use. 

Marchand,§ in 1895, studied a number of cases, and reviewed those already published. 
His conclusion was that the disease is neither deciduoma nor sarcoma, but that it is a malig- 
nant epithelial growth of the chorionic villi, which arises from parasitic cells in the uterine 
mucosa. He calls the disease chorio-carcinoma. Some other names applied to the condi- 
tion have been syncytioma malignum, carcinoma syncytiale, placentoma malignum, and 
deciduo-sarcoma. There seems to be considerable evidence that the growth closely resem- 
bles certain of the endotheliomata, and therefore it cannot with accuracy be called a sarcoma. 
Most cases occur before the age of thirty-five, and the observed limits have been seventeen 
and fifty-five, with which statement all experiences agree. W. Williams || in America, 
R. Williams ** in England (1896) , and M. Cazin ft in France are among those who have most 
recently reported cases and studied their pathology, and it is from such scattered indi- 
vidual experiences that evidence as to the exact character of the disease is gradually accu- 
mulating. 

Pathology. — So far there has been no general agreement on the question of 
the pathology of this growth. According to March and, J! Neumann, and Haul- 
tain,^ who have studied the matter, it seems to be demonstrated that the 
growth is a chorionic epithelioma, grafted upon the maternal tissues by the 
fetus. In most of the cases a very characteristic feature is to be observed 
in the so-called syncytium, a mass of plasmodium containing large nuclei, but 
not otherwise divided into cells (Fig. 244). This syncytium, when growing in 
cases of deciduoma malignum, seems to have a special tendency to open blood- 
vessels and to penetrate the venous sinuses, this quality explaining the rapid 
metastasis, and the resemblance of the disease to some forms of sarcoma. In 
a few cases the syncytium has shown signs of cellular division, and has thus 
given apparent reason for classifying the growth as sarcoma. Herzog || | is 
convinced from his own observations and those of Peters, His, Van Heukolom 
and others, that the syncytium is derived from the fetal ectoderm, and there- 

* "Wiener med. Jahrbuch," 1877. f'Virchow's Archiv," 1877. 

% " Centralblatt f.'Gynakologie," 1889, p. 132. 

§"Monatsschr. f. Geburtsh.," 1895, p. 513. 

|| "Johns Hopkins Hospital Bulletin," 1895. 

** "Uterine Tumors," New York, 1901, p. 343. 

ft "La Gynecologie," Feb., 1896. %% Loc. cit. 

§§ "Jour. Brit. Gyn. Soc," 1899. |||| "Histology of the Placenta." 



DISEASES OF THE DECIDUM. 



207 



fore considers this malignant new growth to belong with epiblastic epithelial 
neoplasms. There seems, therefore, now no doubt that the growth is of fetal 
origin and is grafted upon the maternal tissues. The histological structure 
of deciduoma malignum resembles in general that of placental tissue pursuing 
an atypical course, and bears the same relation to normal placenta that a car- 
cinoma of the breast bears to the normal mammary gland. 

Etiology. — The cause of the disease is not known, any more than the cause 
of malignant disease of other histological characters, and we are able to deduce 
only a few facts in connection with the question of etiology. Multipara are 
almost exclusively the victims of the disease, and a history of vesicular mole 
is given in a very large proportion of cases. The percentage of antecedent 



m.t 




s.t. 



g.c — 







Fig. 243. — Sagittal Section through the Pel- 
vic Organs of a Patient with Chorio-epithe- 
lioma Malignum. — (Marchand.) b, Bladder; 
t.v., t.v , tumor of the vagina ;m.t., m.t., malignant 
tumor; c, cervix; r, rectum; s. a.m., sphincter 
ani muscle. 



Fig. 244. — Chorio - epithelioma 
Malignum . — ( Ulesco-Stroganowa.) 
s.t., s.t., syncytium tissue; g.c, 
g.c, giant cell; e.c, e.c. ecto- 
dermic cells (chorion epithelium) . 



mole pregnancy has been variously given at from 45 to 80, by different authors. 
A decidual cell malignant growth of the testicle, with metastases, has recently 
been described by Schlagenhaufer,* and is perhaps only one of a series of 
anomalous growths in this locality. It appears to show that deciduoma 
malignum has a much more deep-seated origin than has been supposed, one 
which even transcends sex, and is in the truest sense of embryonal origin. 

Symptoms. — The first symptoms, usually occurring within a few weeks of 
the emptying of the uterus, are metrorrhagia, rapidly developing anemia and 
prostration, and phenomena of septic intoxication. A foul, watery discharge 



* "Ctbl. f. Gynakol.," Jan. 17, 1903. 



208 PATHOLOGICAL PREGNANCY. 

may be present, when the bleeding is not going on, and portions of the growth, 
more or less necrotic, may be discharged from time to time (Fig. 243). The 
uterus will be found enlarged, and perhaps irregularities may be felt on its sur- 
face. Pain is a variable symptom. Sometimes portions of the intrauterine mass 
can be removed with the fingers, and may be mistaken for clots, which they 
closely resemble. Later there are signs of metastasis, and also very exten- 
sive local involvement in the form of masses and nodules in the vagina, labia 
and inguinal regions. These look and behave like the most vascular and malig- 
nant sarcomatous tissue. When this stage of the disease is reached, the 
decline of the patient is very rapid, and she soon succumbs to sepsis and ex- 
haustion. 

Diagnosis. — When hemorrhage or hemorrhagic discharge persists after abor- 
tion, normal delivery, or especially after vesicular mole, scrapings from the 
uterine cavity should at once be carefully examined by the pathologist, since 
if anything is to be done for the patients who are unfortunate enough to develop 
this disease, it must be done at once, early diagnosis affording the only way to 
hopeful treatment. 

Treatment. — The only prospect of real and permanent benefit, in the pres- 
ence of deciduoma malignum, lies in hysterectomy, preferably by the vaginal 
method; but, at any rate, by any method which ensures the complete removal 
of the local disease. After metastases have formed no operation can do any 
good. R. Williams has collected fourteen instances of operation by vaginal 
hysterectomy, of which twelve survived the immediate effects of the operation, 
five of these dying within the first year. Of the remainder, six were free from 
disease for periods of from three to ten months, at the time when the report 
was made. Whatever treatment, other than merely palliative, is undertaken, 
it must be most prompt and radical, in order to offer any chance of success. 



II. DISEASES OF THE CHORION. 

I. Cystic Degeneration of the Chorionic Villi. Hydatidijorm or Vesicular Mole. Myxoma 
Chorii Multiplex. 2. Fibromyxomatous Degeneration of the Chorion. 3. Chronic Choriitis. 

1. Cystic Diseases of the Chorion. — Synonyms. — Hydatidiform, Hydatiform, 
Hydatoid, Placental, Vesicular, or Cystic Mole; Uterine Hydatids; Cystic disease 
of the ovum ; Hydatidiform or myxomatous degeneration of the chorionic villi ; 
Cystic degeneration of the villi of the chorion ; Dropsy of the villi of the chorion ; 
Molar pregnancy. 

Definition. — This disease consists in a cystic formation at the ends of the 
villi, giving them the appearance of berries or grapes (Fig. 247). 

Frequency. — The disease is very rare; Madam Boivin, of Paris, found it one 
case in 20,000. I have seen it four times in 15,000 cases of labor observed 
in hospital and private practice. It is oftenest found in multiparas, especially 
between the ages of twenty-five and forty. It is characterized by the tendency 
to recur in the same patient in subsequent pregnancies. Mayer has reported 
eleven cases of this disease in one patient. Hydatiform mole develops usually 
in the first few months of pregnancy, and very rarely after the fourth month. 
When occurring within the first four weeks, death of the fetus rapidly follows, 
in some cases with complete absorption. If the development is later, in the 
second or third month, the fetus, although it may die, may be saved, if too 



DISEASES OF THE CHORION. 



209 



much of the membranes and placenta be not involved. If the death of the 
fetus does occur at this period, there is rarely complete absorption. As has 
been stated, the disease is far more common in the latter part of the woman's 
sexual life; according to some authorities, 22 per cent, are found in the fourth 
and fifth decennia. 

Pathology. — This cyst formation is the result of a myxomatous degenera- 
tion of the tips of the chorionic villi, giving rise to the term myxoma chorii 
In the formation of this growth, the syncytium plays a most important role 
and appears to give the first impulse toward the changes in the villus. Large 
masses of syncytium and chorionic epithelium bore their way into the uterine 
walls, suggesting a malignant growth (see Deciduoma Malignum). Not only 
do the epithelial cells proliferate, but also the connective tissue with its vessels. 
The resultant translucent vesicles contain a fluid closely resembling the liquor 
amnii, and in size they range from that of a millet-seed to that of a walnut. 
The mass in toto may grow as large as a man's head, absorbing the nourishment 
intended for the fetus, which usually dies, while the mole develops over the 
whole surface of the chorion (Fig. 247). 
The arteries of the degenerated villi 
become obliterated, with destruction of 
the decidua. Uterine pains begin, as a 
rule, in the fourth or fifth month. At 
times the mass is so intimately connected 
with the uterus that its expulsion is very 
difficult. Sometimes the growth erodes 
the great blood-vessels, causing fatal 
hemorrhage. The vesicles possess the 
same form as the elements of the original 
chorion of the first two months, and this 
accounts for the peculiar grape- or berry- 
like appearance of the tumor-mass. Either 
the whole surface of the chorion is covered 
with these cysts, which replace the villi, 
or only the placental region is affected. 
The former happens when the mole forms 
in early pregnancy, before the develop- 
ment of the placenta; and the latter if 
the mole does not develop till after the 
placenta. In the first case the fetus 
naturally perishes; in the second, it may 
come to maturity. 

Diagnosis. — This can be made to a 
certainty only by palpating the cysts. 

They may be felt during hemorrhage when the cervix dilates somewhat. 
There is no reason to doubt the invariable association of this disease with preg- 
nancy. Mistakes have sometimes been made by confusing true hydatid cysts 
which have been discharged from the uterus, with the little bladder-like growths 
of the mole. Hewitt has reported a case in which hydatids, which were originally 
in the liver, had extended to the peritoneum, and were just at the point of 
bursting through the vagina at the time of the patient's death. It must also 
be remembered that hydatids may be retained in the uterus for a long time 
and then be discharged; or a few are left behind that may give rise to a new 
set of growths, and these be extruded long after impregnation. When true 
14 




Fig. 245. — Cystic Chorion in Twin 
Pregnancy. Hemorrhagej During 
Labor. — {Bensinger.) 



210 



PATHOLOGICAL PREGNANCY. 



hydatids obscure the diagnosis, it can always be cleared up by microscopic 
revelation of the characteristic heads and hooklets of the echinococcus. 

Etiology. — The essential cause is not yet determined. Marchand thinks 
it most probable that the condition is due primarily to a change in the ovum, 
an argument being the coexistence of a normal ovum and a mole. Perhaps 
even in its early development a dropsical condition of the connective tissue 
of the chorion takes place. In cases of twins, one may be perfectly healthy, 
while the other is affected (Fig. 245). Some ascribe the cause to disease of the 
mother; the arguments for this theory being the occurrence of a mole several 
times in the same woman, and its frequent association with uterine fibroids, 
cancer, or syphilis. Virchow believed it to be due to endometritis. As already 
stated, it seems most prone to affect older women. Other causes assigned are 
pre-existing metritis, chronic deciduitis, uterine fibroids, maternal syphilis or 
carcinoma, absence or deficiency of allantoic vessels, fetal syphilis or other 
disease, fetal death (Gierse, and Grailly Hewitt). Thus the interesting problem 
is yet undecided. Is this disease of fetal or maternal origin? Both theories 
may be right, the disease sometimes probably following 
the death of the embryo, while at others it is due to some 
unknown maternal cause. 

Symptoms and Clinical History. — At first there is nothing 
to call attention to the existing disease, and it is only with 
the advancement of pregnancy that the characteristic symp- 
toms appear. Three symptoms are most characteristic of 
this peculiar disease: (1) The uterus enlarges far more 
rapidly than in pregnancy. (2) Hemorrhage occurs, small 
in amount, or diffuse, irregular, varying in duration from 
several hours to as many weeks. These hemorrhages 
become more severe as the vesicles grow into the decidua, 
and consist of watery and sanguineous discharges, which 
have been likened to currant-juice in appearance. They are 
probably caused by the breaking-down of the cysts, which 
result from painless uterine contractions. It is only from 
the presence of cysts in the discharge that the diagnosis can 
be certainly established. The great increase in size of the 
uterus is not apparent till the third or fourth month. (3) 
There is a cystic or doughy feel on palpation, while the 
outlines of the fetal tumor are very obscure, and no fetal 
heart sounds can be heard. The hemorrhages may be 
frequent and profuse, or one attack may prove quickly fatal. 
When the cysts are found in the vaginal discharge the diag- 
nosis is certain. They are whitish, sago-like bodies, generally 
•surrounded by small blood-clots. There are numerous reflex symptoms result- 
ing from the enlarged abdomen; viz., excessive nausea, vomiting, faintness, even 
syncope, and abdominal, lumbar, or sacral pains. Extreme exhaustion may 
develop. The abdominal pains may possibly be caused by the growth of the 
vesicle into the uterine substance (Fig. 246). Renal insufficiency and albu- 
minuria are not uncommon. When the cystic change extends to involve the 
uterine wall, the disease assumes a semi-malignant character, and septic peri- 
tonitis and death may result from perforation of the uterus. The lower third 
of the uterus is tense. Ballottement is obscure. 

Prognosis. — The patient rarely goes to term, and the fetus is generally 
destroyed, often completely absorbed. The maternal mortality is 13 per cent. 




Fig. 246. — Cystic 
Chorion Per- 
forating THE 
Walls of Ut- 
erus. — ■ (Spie- 
gelberg.) 



DISEASES OF THE CHORION. 211 

The causes of maternal death are hemorrhage, septic infection, and uterine 
perforation with peritonitis. Generally the fourth or fifth month of pregnancy 
sees the expulsion of the ovum, which is favored by the unusual growth and 
consequent overdistention of the uterus, as well as by the irritation caused 
by the penetration of the uterine substance. Rarely, a group of cysts may 
be extruded without interrupting the course of pregnancy. 

Treatment. — After the condition is discovered the uterus should be emptied 
in order to prevent infiltration of the uterine wall by the syncytium. The 
cervix may be dilated if necessary by any of the approved methods and the 
growth removed by the fingers or curette. The latter should be carefully used 
on account of the danger of uterine perforation. After evacuation of the 




Fig. 247. — Cystic Disease (Myxoma) of the Chorion. Hydatidiform Mole. — (Photo- 
graph of the author's specimen) 

uterine contents, the woman should be treated as a puerperal patient. Full 
doses of ergot should be given for some days after the removal of the mole. 
2. Fibromyxomatous Degeneration of the Chorion, or Myxoma Fibrosum. — 

This disease is even more rare than the preceding. It is limited, as a rule, to 
the placental area, and occurs during the latter part of pregnancy. It has 
been described by Virchow and Hildebrandt, and is characterized by fibroid 
degeneration of the connective tissue of the chorion at the placental site. Small 
tumors are formed that eventually undergo myxomatous degeneration. After 
this change has taken place the parts concerned have a soft, gelatinous feel. 
The fetus may not be destroyed, on account of the tardy development of the 
disease. The symptomatology is not clear, and labor may take place before 
the diagnosis is made. The treatment can only be symptomatic. 



212 



PATHOLOGICAL PREGNANCY. 



3. Chronic Choriitis, or Inflammation of the Chorion. — The chorion shares 
the characteristics of other vascular tissues, in being subject to low grades of 
inflammation. From this cause dense adhesions are formed between the 
chorion and the amnion and the decidua. Syphilis may often account for this 
condition. Or, an endometritis may be the forerunner of inflammation of the 
decidua, in which the chorion takes part. Abortion will probably result. The 
treatment is symptomatic. 



III. ANOMALIES OF THE AMNION AND LIQUOR AMNII. 

I. Plastic Exudation, Amniotitis. 2. Abnormal Tenuity. 3. Cysts and Dermoids. 4. 
Premature Rupture, Amniotic Hydrorrhea. 5. Anomalies in Color and Composition of 
Liquor Amnii. 6. Oligohydramnios. 7. Hydramnios. 

Introduction. — Anomalies in the formation of the amnion are without 
practical interest. As might logically be expected, the similarity between 
the pathology of this fetal membrane and that of other serous structures is 
very striking. There is the same 
chance for the occurrence of changes 
of secretion, inflammations, exuda- 
tions, serous and plastic, and bands 





Fig. 248. — An Amniotic Adhesion Ex- 
tending from the Scalp to the Edge 
op the Placenta, and Twisted Around 
the Umbilical Cord. The Fetus Has 
a Double Hare-lip. — (Winckel.) 



Fig. 249. — Normal and Pathological 
Amnion Epithelia. I, Normal amnion 
epithelia; II, amnion epithelia in hy- 
dramnios; III, the same with giant cell. 
— (Ahlfeld.) 



of adhesions. In case of disease of the amnion, however, its function and its- 
intimate relation to the embryo and fetus cause symptoms and sequelae which 
are peculiar to the affections of this particular organ. 

1. Plastic Exudation, Amniotitis or Amnitis. — This affection generally 
occurs in embryonal life, when the amnion lies against the developing skin 



ANOMALIES OF THE AMNION AND LIQUOR AM NIL 213 

of the child, and it is due to the scarcity of liquid, and its failure, consequently, 




Fig. 250. — Amputation of Arm by Amniotic Adhesions. 



to lift the fetal membrane from the child's body 
sive, two results may follow: First, 
the decidua becomes detached, and 
this is naturally followed by death 
of the fetus and severe hemorrhage 
from the maternal vessels. Second, 
a great many fetal malformations 
may occur, for bands of plastic exu- 
dation are formed, which connect 
the fetus and amnion. As the am- 
niotic cavity grows, these bands are 
stretched, and they may connect 
different parts of the fetus, or one or 
both ends may freely float in the 
surrounding liquid. There are no 
blood-vessels in these bands. At 
times they prevent the normal arch- 
ing over of the body-cavities, and 
eventration, anencephalus, or other 
anomaly of non-union results. Spon- 
taneous or intrauterine amputations 
not infrequently follow amniotitis; 
the bands may wrap around a limb, 
and so constrict its blood-supply 
that its further development is im- 
possible; and there is either perfect 
separation, or the part, hindered in 
its growth, atrophies. If the limb is 
completely amputated, and this has 
happened before the third month of 
pregnancy, there will probably be 
entire absorption of the member be- 
fore birth. If later than this period, 
the amputated part may be extruded 



When this condition is extern 




Fig. 251. — Deformities of the Face and 
Skull Caused by Amniotic Adhesions. 
—(Lepage.) 



214 



PATHOLOGICAL PREGNANCY. 




Fig. 252. — Dermoids of the Amnion. I, 
Multiple dermoids (£) ; II, one of the der- 
moids with daughter-cyst. — (Ahlfeld.) 



in labor after the birth of the child. The idea that the umbilical cord produces 
amputations is erroneous, for the cord itself would be so compressed in such a 
case that its circulation would be interfered with, and the child would die of 

asphyxia. The amniotic covering of 
the placenta may also become at- 
tached to various parts of the body, 
or the coils of the umbilical cord may 
adhere in places to each other, or to 
parts of the fetus, and so its length 
be much shortened. Sometimes ad- 
hesions between the amnion and fetus 
are not accompanied by oligohy- 
dramnios, and are then supposed to 
be caused by arrest of development. 
Such deformities as webbed toes and 
fingers then arise (see Monstrosities) 
(Figs. 248 and 249). 

2. Abnormal Tenuity. — In the lat- 
ter part of gestation, on account of 
abnormal tenuity or thinness, the 
amnion may rupture and become 
separated from the chorion. The 
latter remains intact, while the am- 
nion is rolled on itself, forming cords 
or bands, which may wind around 
the fetus, or become so entangled with the umbilical cord as, by constriction, 
to cut off its blood-supply, thus causing the death of the fetus. 

3. Cysts, Dermoids. — The formation of cysts in the substance of the amnion 
has been described; they are small and of no clinical importance. Dermoids 
have also been described. One has 

been observed that was attached by a 
pedicle to the amnion of an aborted 
fetus. Besides cysts, caruncles and 
tuft-like growths have been noted in 
connection with the amnion. In the 
case of fetal death, certain changes 
take place in the amnion, which result 
in the loss of its glistening appearance, 
and in a considerable thickening of its 
substance. The histology of this con- 
dition is not understood (Fig. 252). 

4. Amniotic Hydrorrhea. — Rupture 
of the amnion may be followed by 
abortion. Now and then, however, the 
amnion and chorion are ruptured at a 
point remote from the internal os, and 
the amniotic liquid drips away for 
weeks before labor. This is called am- 
niotic hydrorrhea (Fig. 254). 

5. Anomalies in Color and Composition of the Liquor Amnii. — The color, 
which in the latter part of gestation is normally an opaque white, may become 
reddish from the presence of a macerated fetus, or it may be green or brown, 




Fig. 253. — Compression of the Fetus 
in Oligohydramnios. — (Ahlfeld.) 



ANOMALIES OF THE AMNION AND LIQUOR AMNII. 215 



from the escape of fetal meconium. When the amount of liquid is extremely 
small, its consistency may resemble that of molasses or mucus. If the mother 
has diabetes mellitus, it may contain sugar. Sometimes the liquor amnii is 
decomposed. This is generally coincident with the death and putrefaction 
of the fetus, in which case a true physometra (gaseous products of putrefaction) 
is present to a certain degree. However, instances in which, with this condi- 
tion, the fetus was born alive are on 
record. For such cases no explana- 
tion has yet been given. 

6. Oligohydramnios consists of a 
deficiency of the amniotic liquid. 
This is a rather rare condition, occur- 
ring only once in three or four thou- 
sand cases. The great disadvantages 
of this affection are seen in the 
early part of pregnancy; for the 
uterine walls are not sufficiently sepa- 
rated, and consequently fetal deformi- 
ties occur, such as talipes, bowing of 
the limbs, ulcers on the prominent 
parts of the body from the constant 
friction, adhesions between the am- 
nion and fetal surfaces, and intra- 
uterine amputations. In some cases 
abortion occurs, as the growth of 
the fetus is seriously interfered with. 
When this condition continues into 
advanced pregnancy, the uterus is 
strikingly small and hard. The move- 
ments of the fetus being limited, the 
mother becomes so conscious of them 
as actually to suffer discomfort or 
pain therefrom. Labor is generally 
difficult and abnormally prolonged. 
No treatment is available, even though the condition is diagnosticated before 
birth. 

7. Hydramnios, Polyhydramnios, Hydrops Amnii, or Dropsy of the Amnion. — 
Definition. — This condition consists in the excessive accumulation of amniotic 
fluid in the amnion, or of a deficient absorption of the same. 

Pathology. — It is difficult to estimate exactly the normal amount of liquor 
amnii, for in labor it dribbles away and is mixed with blood; but approximately 
it measures from one to two pints. If there is much more than this quantity, 
hydramnios exists. The condition is not pathological until about five pints 
accumulate. In general, the liquid collects gradually but persistently, giving 
a chronic form to the affection, till at term it may reach six gallons and more. 
There is a condition known as actite hydramnios , in which the increase is very 
rapid, and from the resulting distention of the uterus grave symptoms super- 
vene. It may develop within a few days, or, as in a case reported by Sentex, 
in a single night. This affection usually occurs in early pregnancy, and at the 
fifth or sixth month the abdomen is as large as it would normally be at the 
ninth or tenth month, or even larger. Schneider observed thirty liters at six 
months. The character of the liquid is generally like that of the normal liquor 




Fig. 254. — Diagrammatic Representation 
of the Different Varieties of " False " 
Amniotic Cavities and Waters. a, 
Amnio-chorionic water; d, decidual water; 
t, true amniotic cavity and liquor amnii 
proper. — (Buntm.) 



216 PATHOLOGICAL PREGNANCY. 

amnii. Prochownik states that it contains more urea than is normally present, 
owing to excessive secretion of the fetal kidneys. This condition is frequently 
associated with monsters ; hydrocephalus, hemicephalus, spina bifida, cleft palate, 
harelip, club-foot, or some other deformity is present in 10 per cent, of cases. 

Frequency. — Acute hydramnios is said to occur once in 250 or 300 cases. 
It is more frequent in multigravidae than in primigravidae (23 to 5) ; more frequent 
in twin pregnancies of the same sex than in single pregnancies. There are somec 
ases of twins in which one sac contains more liquid than normal, while the other 
contains less. This condition has been observed in extrauterine pregnancy. 

Etiology. — Three general causes are accepted in the etiology of this affection : 
(1) Fetal, (2) maternal, (3) amniotic. In abnormal states, in which the liquor 
amnii comes in contact with the floor of the fourth ventricle, fetal diabetes 
mellitus is caused, and, in consequence, an excess of fetal urine in the amniotic 
fluid. Changes or obstructions in the umbilical vein, such as phlebitis and 
thrombosis, also torsion of the cord, will cause damming back of the blood, 
and resulting transudation of serum. A large fetal bladder, by pressure on 
the vein, will force the blood back into the placenta. Lesions of the liver, 
the heart, the blood-vessels, or the kidneys of the mother, by interfering with 
circulation, may cause this trouble. Albuminuria, diabetes, and syphilis have 
been claimed as sources of the affection, as well as leukemia and anemia. The 
amount and degree of transudation through the amnion has been proved by 
Sallinger to depend upon the strength of the blood-pressure in the umbilical 
vein, and upon the size of the cord. Tumors of the placenta, causing an increased 
blood-pressure, will cause transudation, as will also fetal tumors that obstruct 
the circulation. The fetal skin may be the source of hydramnios. An abnor- 
mal blood-supply, sent by a hypertrophied heart, may excite the skin to 
extra activity. Other cases of extensive naevi, thickened skin, and elephan- 
tiasis congenita cystica, have been reported in association with hydramnios. 
The amnion itself may be productive of hydramnios. The condition of acute 
inflammation, amniotitis, may be followed by extreme serous exudation. This 
etiological factor would explain cases of hydramnios which follow traumatism 
of the abdomen of a pregnant woman. Adhesions between amnion and fetus 
have been developed in such cases. Acute hydramnios has also been ascribed 
to this cause. McClintock reports that in about 75 per cent, of the cases he 
has studied the fetus has been of the female sex. Hydramnios is at times ob- 
served in association with serous effusions in other parts of the maternal organ- 
ism. It would therefore be of value in this trouble to make a blood examina- 
tion of the mother, in order to ascertain if the hydremia so commonly found 
in pregnancy is increased. Certain cases of dropsy of mother and child, 
associated with this affection and syphilitic in origin, have been reported. As 
to the theory of deficient absorption of liquor amnii, those cases of hydramnios 
coincident with nephritis and serous effusions in the mother could be explained 
in this way. In this affection the fetus is often born dead and shriveled, and 
the placenta is enlarged and cedematous. Maternal mortality after labor is also 
high, probably dependent upon the debilitated state of the patients. The large 
majority of cases which admit of any explanation — for, according to Bar, 44 per 
cent, of all cases have no demonstrable cause — can be traced to a fetal origin. 

Symptoms. — In the acute form the symptoms are sudden, often intense, 
pain; fever, from the acute inflammation of the amnion; a great and rapid 
abdominal distention; inability of the patient to lie down; irregularity of pulse 
and respiration, dyspnea, and lividity of the face. The symptoms may be 
slight or pronounced. In the chronic form the undue pressure of the uterus 



ANOMALIES OF THE AMNION AND LIQUOR AMNII. 217 

on the abdominal contents causes impeded respiration, and palpitation of the 
heart, from the upward displacement of the diaphragm. But in this form 
the accumulation of the liquid is gradual, and is consequently not followed 
by the severe symptoms of the acute form. The distention becomes notice- 
able about the third or fourth month. It gradually and slowly increases, 
causing little discomfort to the mother. The patient is often somewhat de- 
pressed, but suffers little disturbance in general health. Sometimes insomnia 
is present, caused by the sensation of weight in the pelvis, which does not 
amount to real pain. Neuralgia of the abdominal walls, pelvis, and lower 
extremities results from pressure on the pelvic and sacral plexuses ; and oedema 
of the abdomen, genitalia, and limbs, from obstructed pelvic circulation. There 
are excretion of scanty and albuminous urine, from interference with the renal 
circulation; digestive disturbances, as a reflex result of great uterine distention, 
or from the direct pressure on the abdominal viscera; and at times ascites, 
caused by pressure upon the portal vein. As a rule, the symptoms of preg- 
nancy are increased in severity. The abnormally rapid increase in size of the 
uterus is the most striking symptom of this condition. Relief is often afforded 
by the occurrence of premature labor, the first stage generally being tedious, 
from the overdistention of the uterus. From this same cause there is a greater 
tendency than normal to post-partum hemorrhage, just as in the case of twins. 

Physical Signs. — On inspection, we find abnormal distention of the abdo- 
men. Palpation shows an enormous uterus, with tense and rather elastic 
parietes, and vague fluctuation. The fetus may be easily moved from one 
point to another, or even inverted. Auscultation reveals either a total absence 
of fetal heart sounds, or a muffled tone. Vaginal examination will show the 
elevation of the os, with a partial obliteration of the cervical canal. The lower 
uterine segment is elastic and tense, and the presenting part of the fetus cannot 
be readily palpated. 

Diagnosis. — As a rule, the diagnosis is not difficult. If there exists a larger 
uterus than normal, the diagnosis of hydramnios is justifiable. There is, too, 
the history of pregnancy to add its weight of evidence. However, difficulties 
not uncommonly arise when there is a large collection of fluid, and when the 
fetus is small, or dead, so that there is an absence of fetal heart sounds and 
movements. It often occurs that, even though the enlarged uterus will give 
a liquid wave as distinct as that felt in an ovarian cyst, still by dipping deeply 
on palpation, the solid body of the fetus can be detected. The fetus will be 
abnormally movable. Differential diagnosis between hydramnios and ovarian 
cyst may be made by observing the following point: the development of hy- 
dramnios is far more rapid. If there exist (i) the fetal heart sounds, (2) if 
the fetal body can be mapped out, (3) if the hypertrophied round ligaments 
can be traced, ovarian cyst can be excluded. The normal position of the 
uterus, whether pregnant or not, is low down in the pelvis in ovarian dropsy, 
while in hydramnios it is drawn high up, and felt per vaginam with difficulty 
(Kidd). The facies of ovarian trouble is characteristic in advanced cases. 
Finally, emaciation occurs. A most valuable distinction is the presence of 
Braxton-Hicks's sign, which always exists in pregnancy, — the occasional rhyth- 
mic contractions of the uterus, especially when excited by manipulation. If 
it can be proved that the hardening of the uterine wall thus produced extends 
over the whole surface of the tumor, then it is positive that the whole mass 
is uterus. When from its great distention the uterus resembles a large ovarian 
cyst, the cervix will generally yield more than it normally does at the fifth 
or sixth month of pregnancy, so much so that the finger can be inserted within 



218 PATHOLOGICAL PREGNANCY. 

it till it reaches the membranes. Hydramnios may be confused with preg- 
nancy complicated with ascites, though it may be distinguished, before it has 
proceeded too far, by mapping out the uterine parietes, and by the detection 
of resonance along the flanks, in the dorsal decubitus; or with a cystic tumor 
of the broad ligament, or with a normal twin pregnancy. This diagnosis may 
be difficult or even impossible, but usually in hydramnios the uterine enlarge- 
ment is more tense or fluctuating. The fetal membranes may be palpated, 
and the lower uterine segment, felt by vaginal examination, is generally dis- 
tended, and the presenting part not palpable. This condition has been mis- 
taken for distended bladder, with retroversion of the uterus. When the uterus 
is extended to its extreme limit, and a certain diagnosis cannot be made, the 
advisability of an abdominal exploratory operation should suggest itself, since 
but slight danger attends such a procedure. Abdominal ascites pure and simple 
must also be distinguished by the superficial position of the fluid, the difficulty 
of mapping out the uterus, and the physical signs, which show that the fluid 
exists free in the peritoneal cavity, and by the presence of dropsical effusions 
in other parts of the body. The area of dulness is variable, depending upon 
change of position of the patient. There is decrease in the quantity of urine 
and it is whitish and turbid. Extreme and constant thirst is present. There 
is a great distention of the hypochondria. In an extreme degree of ascites 
there is marked protuberance of the umbilicus. 

Prognosis. — Authorities differ as to the gravity of the prognosis. It cer- 
tainly is not very good for the mother, though naturally it depends on the 
cause of the existing condition. McClintock, out of thirty-three patients with 
hydramnios, lost four by rupture of the uterus; two by exhaustion; one by 
infection. Winckel lost one by pre-existing pneumonia, while another had 
an attack of paracolpitis, and parametritis, although she recovered. The preg- 
nancy has a decided tendency to terminate early, from the extreme uterine 
distention, from the death of the fetus, or from the untimely detachment of 
the placenta; thus subjecting the patient to all the risks of abortion. Post- 
partum hemorrhage is very apt to occur on account of the uterine inertia, 
caused by extreme distention, and consequent weak labor pains and protrac- 
tion of labor. Involution is prolonged, or not fully completed. Death may 
be a sequela, due to exhaustion, particularly in the acute variety. Fetal prog- 
nosis is unquestionably bad. Fully 25 per cent, of the children die. This 
high degree of mortality follows from fetal malformations, dropsical troubles, 
prematurity, and the frequency of abnormal presentations. Charpentier col- 
lected 113 cases, in which 20 presented by the shoulder, 21 by the breech, and 
2 by the face. Many fetuses are in a diseased condition, and after birth show a 
variety of pathological conditions: viz., syphilis, hydrocephalus, or elephantiasis. 
The common occurrence of prolapsed cord also adds to the fetal mortality. 

Treatment. — The treatment should generally be expectant. The acute cases, 
however, should undergo immediate evacuation of the contents of the uterus. 
The os should be dilated and the membranes then punctured. The method 
of aspiration of the fluid through the walls of the uterus should not be counte- 
nanced. The precipitate discharge of the fluid should be avoided; the hand or 
gauze may be used as a plug. Serious cardiac disturbances on the part of the 
mother, or extreme discomfort, should indicate premature delivery. Espe- 
cially if there is danger of death, labor should be immediately induced. It 
has been suggested to insert a minute aspirating needle through the os, and 
thus remove a part of the amniotic liquid, in order to relieve the distressing 
symptoms, but not to bring on labor. This should, of course, be delayed as 



ANOMALIES AND DISEASES OF THE PLACENTA. 219 

long as is consistent with the safety of the mother, although the great possibility 
of a monstrosity, or at least of a poorly developed child, takes away from the 
serious aspect of prematurely induced labor. In such cases, measures to pre- 
vent hemorrhage should be instituted. The malposition of the fetus should 
also be guarded against. 

Chronic hydr amnios should be treated by the application of an abdominal 
binder (Fig. 233) and enforced rest on the part of the mother, in order to give 
the fetus the best opportunity to survive. In mild cases, interference is 
not necessary; but if severe respiratory or cardiac symptoms, great exhaustion, 
etc., are present, the pregnancy should be terminated, as in the acute form. 
The liquor amnii should be allowed to escape slowly, in order to avoid syncope 
prolapse of the cord, and hemorrhage from premature detachment of the pla- 
centa. The precautions against hemorrhage should be observed, and every 
endeavor made to secure firm uterine contractions. If the expulsion of the 
fetus be too slow, it must be assisted in some way; although too early appli- 
cation of the forceps should be avoided, for fear of the later hemorrhage. After 
delivery by whatever method, there should be careful observation of the uterus 
for some time, and besides giving ergot, we should stimulate its contractions 
by the firm grasping of the organ and by hot injections. 



IV. ANOMALIES AND DISEASES OF THE PLACENTA. 

I. Anomalies. — (1) Size: (a) Atrophy, (b) Hypertrophy, (c) Placenta Membranacea; (2) 
Form; (3) Number; (4) Relation; (5) Insertion, Placenta Previa. 2. Injuries. — Prema- 
ture Detachment; Accidental Hemorrhage. 3. Stasis and (Edema. 4. Interstitial Hemor- 
rhage — Apoplexy; Infarction; Thrombosis. 5. Placentitis. — (1) Acute Septic, (2) Gonorrheal, 
(j) Emanuel's Disease, (4) Specific, (5) Chronic Interstitial and (6) Albuminuric. 6. In- 
fectious Granulomata, Tuberculous and Syphilitic. 7. Secondary Metamorphosis. — (1) Pro- 
gressive Hyperplastic and Sclerotic, Adherent Placenta; (2) Regressive, Results of Fetal 
Death; White Infarcts; Cystic, Calcareous, Fatty, and Miscellaneous Degenerations. 
8. Tumors. — Placentomata, Polypi. 

General Remarks. — A perfectly satisfactory account of affections of the placenta cannot 
be written because of our ignorance of the histology and development of this organ. No 
distinction can be made between the fetal and maternal placenta from the standpoint of 
pathology, because affections appear in both simultaneously, or pass from one to the other. 

Etiology. — Diseases of the placenta originate as follows: (1) From certain pathological 
conditions in the maternal organism, and especially endometritis which antedates concep- 
tion. (2) From general diseases affecting the mother, as syphilis, tuberculosis, acute infec- 
tious diseases, nephritis, leukemia, exophthalmic goitre. In this class, too, lesion of the 
endometrium is the connecting-link between the maternal and placental diseases. The 
endometritis, however, does not necessarily antedate conception, but may develop during 
pregnancy, the fetal portion of the placenta being the first to suffer. (3) From primary 
disease of the fetus, especially disturbances of the circulation including the umbilical vessels. 
When the fetus dies from whatever cause, certain alterations are regularly produced in the 
placenta, such as obliteration of the vessels and fibrous degeneration of the cells. The con- 
verse, of course, is true, so that disease of the fetal and maternal placenta may cause defective 
nourishment and development of the fetus as well as the death of the latter, not only during 
pregnancy but in the course of an otherwise normal labor. This termination of pregnancy 
may occur repeatedly in the same woman. If the fetus with a diseased placenta survives, 
the increased resistance encountered by the placental circulation may have produced disease 
of the heart or of some of the other viscera. Again, the fetus may not die in utero as a result of 
the placental disease, but the pregnancy may terminate in missed labor, premature labor, 
or premature separation of the normally situated placenta. Placental disease is also respon- 
sible for some cases of hydramnios. We are unable to state whether placental affections 
can affect the health of the mother (nephritis of pregnancy, eclampsia, etc.). They play a 
very prominent role, however, in connection with labor (accidental and unavoidable 
hemorrhage, adhesions, retention, etc.). 

Diagnosis. — There are no known methods by which placental diseases, with the excep- 
tion of placenta prasvia and accidental hemorrhage, may be recognized in utero. 

Treatment. — With the exception of syphilis of the placenta we know of no affection of 
the latter organ which can be affected by treatment. 





Fig. 255. — Irregularly Formed Pla- 
centa. — (Auvard.) 



Fig. 256. — Placenta with Several 
Irregular Lobes. — (Auvard.) 





Fig. 257. — Placenta with Two Equal 
Lobes. — (Ribemont-Lepage.) 



Fig. 258. — Placenta with Two Un« 
equal Lobes. — (Auvard.) 





Fig. 259. — Placenta Succen- 
tu ri at a . — (Ribemont-Lepage.) 



Fig. 260. — Fenestrated Twin Placenta at 
Seventh Month. — (Hyrtl.) 



220 






Fig. 261. — Trilobed Placenta, 
Two Lobes Equal in Size. 



Fig. 262. — Placenta with Two Unequal 
Lobes and Velamentous Cord Insertion. 
— (Ribemont-Lepage.) 



A 




Fig. 263. — Placenta Membranacea. 
(Ahlfeld.) 




Fig. 264. — Bilobed Placenta. 
"Horseshoe" Placenta. 




Fig. 265. — Placenta in Triplets. Three Dis- 
tinct Masses of Placenta, with an Isolated 
Cotyledon. — (Ribemont.) 




Fig. 266. — Small Accessory 
Placenta. — {Ribemont-Le- 
page.) 



221 



222 



PATHOLOGICAL PREGNANCY. 




Fig. 267. 



-Battledore Oval Placenta. 

(Auvard.) 



I. Anomalies. — (1) Size. — (a) Atrophy: By this term is meant simple 
qualitative atrophy, and not the diminution in size which is secondary to in- 
flammatory affections. There is a tolerably definite relationship between the 
fetal and placental weights under normal conditions which is expressed by 
1 : 5-5- When an otherwise normal placenta is of smaller size than this ratio 
requires, a condition of arrested development is present. Nothing whatever 
is known of the causes of primary atrophy, which is seen alike in the ill-nourished 
and the robust, (b) Hypertrophy: Simple hypertrophy is the opposite to the 

condition just described, the pla- 
centa being increased in area and 
thickness although of normal 
quality. It should not be con- 
founded with an cedematous or 
hyperplastic placenta. As this 
condition is encountered only with 
very large fetuses, and preserves 
the habitual ratio, it is hardly to 
be ranked among anomalies. (<:) 
Placenta Membranacea: This rare 
anomaly represents a placenta 
which extends over the greater 
portion or even the whole of the chorionic surface (Figs. 263 and 276). The 
expanded structure is correspondingly thin and membranous in texture. In 
this anomaly there is an evident failure on the part of the decidua serotina to 
develop into the normal placenta, with persistence of the chorionic villi. The 
phenomenon has been explained in various ways. Some see therein an illus- 
tration of atavism, as this form of placentation is normal in the pachyderms. 
Others believe that a failure on the part of the serotina to nourish the fetus 
leads to a broadening of the original placental substratum with consecutive 
splitting of the decidua vera. This 
theory, which necessitates the sup- 
position that the ovum was origin- 
ally embedded too deeply, accounts 
for the thin texture of the membran- 
ous placenta. Clinically this anomaly 
generally constitutes a prasvia (Fig. 
276), and also complicates the third 
stage of labor by retention or actual 
adhesion and resulting hemorrhage. 
Fortunately, it is very rarely en- 
countered in practice. 

(2) Anomalies of Form. — These 
are best considered collectively. The 
principal aberrations in the shape of 

the placenta are as follows: (1) Lobate placenta, in which the organ is divided 
into two or more lobes (Figs. 256, 257, 258, 261, and 262). (2) Horseshoe 
placenta (placenta reniformis) (Fig. 264). (3) Fenestrated placenta, charac- 
terized by one or more solutions of continuity in the substance of the organ 
through which the chorion is visible (Fig. 260). Annular placenta, which ex- 
tends about the uterine cavity like a belt (Fig. 260). Von Franque explains 
these anomalies by the supposition of abnormal development which results from 
endometritis. Some of the chorionic villi failing to develop, the placenta exhibits 



>£ 




Fig. 268. — Placenta with Velamentous 
Cord Attachment. — (Ribemont-Lepage.) 



ANOMALIES AND DISEASES OF THE PLACENTA. 



223 



corresponding defects through which fantastic forms are assumed. Clinically, 
all of the preceding placentae may cause disturbance of the third stage of labor 
through partial detachment 
and retention. They are less 
to be feared in this respect, 
however, than the subse- 
quent class. 

(3) Anomalies of Num- 
ber. — These represent ap- 
parently a higher degree of 
the process involved in the 
genesis of the preceding class. 
Generally speaking, they are 
included under the term 
supernumerary or accessory 
placentae. If these subsidiary 
structures contribute to the 
nourishment of the fetus, 
they are termed placentae 
succenturiatae ; otherwise they 
are known as false placentae 
(placentae spuriae). As many 
as half a dozen of these ac- 
cessory organs have been 
found in a single uterus. 

These anomalies probably 
originate in one of two ways : 
( 1 ) Endometritic prolifera- 
tion during the development 
of the placenta may divide 
the latter into two or more 
segments, some of which may 

be small — mere single cotyledons, in fact. (2) An ovum may be implanted over 
a uterine angle, where a complete placenta would not form; as a result placental 

tissue develops on either side of 
the angle. This particular type is 
known as the duplex or bipartite 
placenta. Multiple placentae as a 
class are said to occur in one labor 
out of about 352 (Ribemont-Des- 
saignes). The most common type 
of multiple placenta is the placenta 
duplex, or bilobed placenta, which 
was encountered by Ahlfeld 5 times 
in 3000 cases (Figs. 256 to 258). 
These anomalies may cause serious 
complications of the third stage of 
labor. The practitioner should al- 
ways examine a placenta carefully 
to make sure that there is no ap- 
parent loss of substance. 
By this term is meant the anomalous rela- 




Fig. 269.- 



Placenta Succenturiata. — (Author's 
case.) 




Fig. 270. — Placenta Dimidiata. — (Ahlfeld.) 



(4) Anomalies of Relation. 



224 



PATHOLOGICAL PREGNANCY. 



tions which may subsist between the placenta and the other fetal appendages 
(membranes, cord). Battledore Placenta: This term is applied to a placenta in 
which the cord has a lateral implantation (Fig. 267). It is considered under 
anomalies of the cord. Placenta Marginata; Placenta Circumvallata: When the 
chorion laeve begins within instead of at the border of the placenta the latter 
necessarily exhibits a free margin and is known as a placenta marginata. When 
the chorion forms a rigid annular fold at the inner limit of the margin, we 
have a so-called placenta circumvallata. These conditions have their incep- 
tion before the placenta has arrived at its normal superficial growth. The 
outermost villi penetrate into the substance of the decidua vera, so that the 
latter is split, its upper segment becoming a part of the reflexa. Through 
some inflammatory process in the latter with resulting fibroid induration, 





Fig. 271. — Diagram Representing the 
Formation of Marginal Placenta 
Previa. The ovum becomes fixed to 
one side of the internal os ; the chorion 
and placenta form, and a marginal pla- 
centa previa results. — (Ahlfeld.) 



Fig. 272. — Diagram Representing the 
Formation of a Central Placenta 
Previa. The ovum becomes fixed just 
over the internal os; the chorion and 
placenta form, and a central placenta 
prasvia results. — (Ahlfeld.) 



the lateral expansion of the placenta is accomplished in an abortive fashion , 
the outer portion being without its normal chorionic investment. During the 
sclerotic contraction of the inflammatory zone in the reflexa, the chorion is forced 
into a sharp fold at its junction with the surface of the placenta (placenta 
circumvallata). As in the case of most of these placental anomalies, the 
essential cause of the marginate and circumvallate forms is to be found in a 
diseased endometrium, which is responsible for the pathological condition of 
the reflexa. A higher degree of the process which causes the placenta mar- 
ginata should, in theory at least, interfere with the growth of the placenta 
to such an extent as to cause the death of the fetus. The clinical significance 
of these placental anomalies is twofold: (1) The amnion and chorion are often 
intimately adherent, so that during expulsion of the after-birth the chorion 



ANOMALIES AND DISEASES OF THE PLACENTA. 



225 



may be torn from the placenta and left behind. (2) The complications pro- 
duced by other placental anomalies, such as incomplete detachment, retention, 
and atonic hemorrhages, are frequently encountered here. 

(5) Anomalies of Insertion; Placenta Previa. — Definition. — The 
placenta is said to be praevia when it is attached to any portion of the lower 
uterine segment, and since dilatation of the segment is necessarily followed 
by hemorrhage from separation of the placenta, the condition is sometimes 
called unavoidable hemorrhage. Hemorrhages of pregnancy in the first months 
are usually due to abortion, menstruation, or lesions of the cervix, and are 



f \m^r 




Fig. 



273. — Diagrams to Represent the Varieties of Placenta Previa According 
to the Definitions Set Forth in this Work. — (Author's classification.) 



not profuse. In the last three months they are almost always due to a pre- 
mature detachment of a normally or abnormally inserted placenta. The former 
is considered under Accidental Hemorrhage. Placenta praevia has also been 
defined as a localization of the placenta over the internal os when the latter 
is dilated (Fig. 273). 

Frequency. — In estimating the frequency of this anomaly as of others in 
obstetrics, account must be taken of the hospital service or private practice 
from which the conclusions are drawn. Thus, we find the proportion given 
15 



226 PATHOLOGICAL PREGNANCY. 

as high as i in 250 and as low as 1 in 1000. In an indoor and outdoor hospital 
service, and in a private practice in which no emergencies and consultation 
cases are seen, the latter figure is not far from correct; while where emergency 
and consultation cases are counted, the proportion may easily approach the 
former figures. Statistics exhibit great irregularities. In some years the 
condition is so frequent as almost to simulate an epidemic. In 2200 preg- 
nancies I found that the diagnosis of placenta praevia was made in 9 cases, 
or 0.40 per cent., or 1 in 244 cases. Three, or 33.33 per cent., were in primiparse, 
and 6, or 66.66 per cent., were in multiparas. One thousand of these patients were 
confined at the New York Maternity, where no emergency cases are received, 
and 1200 at the Mothers' and Babies' Hospital at a time when few cases out- 
side the regular hospital service were cared for. 

Varieties. — In placenta prccvia centralis the placenta completely covers the 
lumen of the os after dilatation is complete. This form is very rare, and the 
placenta is placed to a great extent to one side of the uterus — especially the 
right side (Fig. 273). In placenta prcevia partialis the placenta partly covers 
the lumen of the os after complete dilatation, and there is more placental sub- 
stance on one side of the os than on the other (Fig. 273). In placenta prctvia 
lateralis or marginalis the placenta does not reach beyond the margin of the 
internal os. This is the most common form (Fig. 273). In the lateral variety 
the placenta is situated on the lateral surface of the lower part of the uterus, 
not quite reaching the edge of the internal os. On dilatation of this lower 
uterine segment the placenta may be separated with very little loss of blood. 
In the marginal variety the placenta stretches down to, but not over, the internal 
os. These several varieties can be arranged again in two groups — complete 
and incomplete. The complete variety comprises the placenta prsevia cen- 
tralis, while the three varieties remaining are embraced under the term in- 
complete. 

Etiology. — Placenta praevia is much more common in multigravidae than in 
primigravidae, the proportion being about six to one. Among the various 
causes which may result in faulty attachment of the ovum are conditions lead- 
ing to enlargement and relaxation of the uterus and to changes of shape; e. g., 
multiparity, multiple pregnancy, and uterine malformations; also conditions 
leading to changes in the uterine mucosa, as endometritis, abortions, and tumors. 
It seems more common in the poorer classes ; owing probably to hard work and 
subinvolution of the uterus. Abnormally low position of the Fallopian tubes 
and abnormal size of the uterus are etiological factors. A diseased endome- 
trium is probably the fundamental cause. It is believed by some that in a 
threatened abortion the ovum may be arrested in its descent and become at- 
tached near or at the cervix. Hofmeier and Kaltenbach propose another 
theory, that the placenta is developed both in the decidua basalis and the 
decidua reflexa; adhesion occurs between the reflexa and vera, and therefore the 
placenta may be over the internal os. 

Cause of the Hemorrhage. — It is necessary to understand thoroughly the 
anatomy of the parts concerned in order to form a true idea of their mechanism, 
both normal and abnormal. Before the time of Mueller, Lott, and Bandl, 
the uterus was supposed to consist of two parts, the body and the cervix. The 
body contracted, the cervix dilated; consequently, if the placenta was attached 
to the upper or contracting part, it became separated when contraction took 
place; and this occurring normally only during labor, any previous placental 
detachment must be due to accident. When the placenta was attached to 
the cervix, separation would occur during dilatation of the cervix in labor. 



ANOMALIES AND DISEASES OF THE PLACENTA. 227 

Levret and Rigby accepted this theory, and the latter originated for this patho- 
logical condition the term unavoidable hemorrhage, in contradistinction to 
accidental hemorrhage. These terms are evidently misleading, as they pre- 
suppose an essential difference in the etiology of the two conditions, which is 
far from true in every case. This old theory explains the mechanism of hem- 
orrhages in cases of central and perhaps partial attachment, but not in those 
of marginal and lateral attachment. 

According to our present understanding of its morphology, the pregnant 
uterus consists of three parts which are distinct both anatomically and physio- 
logically. The upper part or body is divided into two sections by Bandl's 
ring, and the cervix forms the third part (Part IV). The physiological func- 
tion of the cervix is active only during labor itself. 

The normal arrest of the ovum is a little below the uterine opening of 
the tubes and above Bandl's ring. This statement is upheld by the fact 
that the placenta is nearly always attached to the side of the uterus. The 
fundal implantation is very rare. The area of attachment is very small in 
early pregnancy and the development of the placenta will conform to the growth 
of that part of the uterus to which it has attached itself. Above, the wall of 
the uterus becomes thicker and ready for its function — contraction; below, it 
becomes thinner and expands. In case the placenta is low down it will for a 
time conform to the uterine changes. First it will enlarge at the point of at- 
tachment, then it will expand to a certain degree; but when the limit is reached, 
then hemorrhage will occur. If the attachment is very extensive or particu- 
larly firm, there will occur partial rupture of the placental substance, or the 
placenta will separate from its base. During labor, as dilatation continues, 
the breech between the uterine wall and the placenta becomes gradually 
greater and greater: with each contraction of the uterus new placental tissue 
is lacerated. The retraction of the uterus from the placenta is most clearly 
seen in those cases in which only a small edge of placenta can be felt when 
the cervix begins to dilate, but in which nearly the whole placenta is lowered 
when dilatation is completed. But this changed position is not so much 
affected by the descent of the placenta as by the ascent of the lower part of 
the uterus. 

The parturient uterus is characterized by three properties : contractility and 
retractility of the upper segment, dilat ability of the lower segment. These 
explain the entire mechanism. This theory seems to be the most satisfactory 
of those advanced, and takes as its foundation the supposition that the lower 
segment of the uterus belongs to the body and not to the cervix. The idea 
is generally current that true decidua is never found on the mucous membrane 
of the cervix, so that the placenta cannot primarily be implanted there. This 
has not yet been positively proved. 

The low implantation of the placenta undoubtedly renders it more liable 
to detachment from mechanical causes — such as shocks, jars, etc. — than when 
it is normally situated. In the upright position of the woman, moreover, the 
blood-pressure is greater in the placenta when it is praevia. The decidua reflexa 
may grow downward and become attached over the internal os. 

Pathology. — The placenta is generally the subject of malformation; its form 
is irregular; it is thinner and covers a larger surface than the normally situated 
placenta; the decidual part is unevenly developed, being very thick above 
and thin below; the upper part is also very firmly attached to its bed, while 
the attachment of the lower part is very slender. The organ may be bilobed 
or there may be a placenta succenturiata, causing errors in diagnosis. The 



228 



PATHOLOGICAL PREGNANCY. 



forms which it may assume are varied. The adhesions between the pla- 
centa and the uterine wall are often abnormal, causing complications in its 
delivery. The insertion of the cord is also abnormal, and it is not often found 
centrally attached, but is apt to be nearer one side than the other. Prolapse 
of the cord is consequently not uncommon. 

Symptoms. — The principal symptom is hemorrhage. It occurs without 
warning and varies from a few drops to an amount sufficient to produce 
grave anemia; the attacks, however, are usually slight at first and increase in 
severity; and the time of the hemorrhage often corresponds to a menstrual 
epoch. It occurs at any time of pregnancy, from the beginning of the third 
month to delivery; it is most frequent in the last month, though it may be 
looked for after the sixth month. The more nearly central the placenta, 
the earlier will be the occurrence of hemorrhage. Most cases of so-called 
menstruation in pregnancy are due to the low implantation of the placenta. 
There is usually no show of blood in the marginal variety till the beginning of 

labor. 

During pregnancy the amount 
of blood lost is not so apt to be 
dangerous, but at the completion 
of gestation or during the com- 
mencement of labor the loss of 
blood may be tremendous, the 
constitutional symptoms of hem- 
orrhage supervening, and with- 
in a few minutes the patient's 
life may be placed in great dan- 
ger, death occurring within a few 
moments of the beginning of 
the hemorrhage. The hemorrhage 
ceases when (i) the separation of 
the placenta is completed; also 
generally after (2) the rupture of 
the membranes, for then (3) the 
presenting part of the placenta 
itself is forced down upon the 
bleeding uterine sinuses, closing 
their openings. 

When labor has commenced, 
each contraction of the uterus 
causes fresh portions of the pla- 
centa to become detached, and consequently fresh vessels are torn and left open. 
The tendency of these contractions, however, in all forms of hemorrhage is to con- 
strict the open mouths of the uterine sinuses and so to control the hemorrhages. 
The apparent increase of the bleeding in placenta praevia during a "pain" is 
due to the contractions of the uterus forcing out from the organ blood which 
had already escaped during the interval. In one way, up to a certain point, 
contractions do favor hemorrhage by detaching fresh portions of the placental 
tissue, but the actual loss of blood comes from the uterine sinuses during the 
interval and not during the contraction. 

Course of Labor. — The first stage is apt to be delayed, since the pres- 
ence of the placenta interferes with the cervical dilatation; unless the 
patient is exhausted by hemorrhage, however, the labor may progress rapidly 




1 m 



Fig. 274. — Placenta Previa in Twin Preg- 
nancy. — (H of meter.) 



ANOMALIES AND DISEASES OF THE PLACENTA. 229 

after the presenting part has entered the cervix, since the latter is usually 
soft and elastic. Rigidity of the cervix is sometimes present (12 per cent., 
Muller). 

Diagnosis. — Early in pregnancy the diagnosis is impossible unless the pla- 
centa is actually palpated, but in the last third of gestation, the character 
of the hemorrhage and, after dilatation has been secured, the palpation of the 
placenta, determine the diagnosis. Inspection and auscultation have no part 
in the diagnosis of placenta prsevia. Little or nothing is to be obtained by 
abdominal palpation, but vaginal exploration is most valuable. The only 
positive evidence of the condition is obtained by palpating the placenta with 
the fingers passed through the os. During labor this is best performed in 
the intervals between the pains, and, fortunately, in the last months of the 
pregnancy the cervical canal is usually yielding and patulous and offers little 
resistance to the finger in the class of patients most often suffering from this 
anomaly — namely, multigravidae. Before dilatation of the os, by palpating 
the lower uterine segment through one of the vaginal fornices, the placenta 
may be made out through the uterine wall between the fingers and the pre- 
senting fetal part. Ballottement will be obscure or absent altogether, and 
the large placental vessels and those of the lower segment may be distinctly 
felt pulsating under the finger. The cervix and vaginal fornices are softer 
than normal and have a boggy feel, due to the increased blood-supply, and 
the presenting part is with difficulty made out through the placental substance. 
These signs are often more marked on one side of the cervix than the other. 
After dilatation of the cervix, if the placenta is centrally attached, the whole 
internal os will be covered over by a thick, boggy mass, soft and granular, 
distinguished from coagulum by its consistency and its resistance to pressure 
of the finger (Fig. 273). Through this placental mass the presenting fetal 
part may be felt, but far less distinctly than in the normal condition. If 
the placental attachment is only partial, the bag of waters will be felt, and 
above it the head, occupying one part of the internal os, while the rest of the 
aperture will be covered by the placental mass (Fig. 273). If the attachment 
is marginal, only the thick edge of the placenta will be made out near the 
rim of the internal os (Fig. 273). 

Differential Diagnosis. — The condition is to be distinguished from acci- 
dental hemorrhage and from rupture of the uterus. (See Accidental Hemor- 
rhage.) 

Prognosis. — Death of the mother is due to hemorrhage and sepsis. The 
nearer to the time of labor the hemorrhage occurs, the better the prognosis, 
as dilatation and emptying of the uterus can more readily be accomplished. 
For the same reason the prognosis is better in multigravidae than in primi- 
gravidae, and during labor than in pregnancy. Again, the danger is greater 
for both mother and fetus the more centrally the placenta is placed, for when 
centrally located a greater number of uterine vessels will be exposed before 
labor can terminate. There is danger also of hemorrhage after birth, as 
the lower segment, flabby and inert from the muscular atrophy which 
follows the distention caused by the abnormal placenta, does not completely 
occlude the vessels left gaping after detachment of the latter. The cervix 
and lower segment should be very carefully guarded, as mechanical manipu- 
lations — especially in rapid dilatations and extractions — may fatally tear these 
parts (Fig. 799). Death may supervene suddenly after the bleeding has 
entirely ceased, from the great constitutional depression which follows the loss 
of blood. 



230 



PATHOLOGICAL PREGNANCY. 



The increased risk of septic infection is due (i) partly to the greater ten- 
dency which the vessels have for absorption as a consequence of their emptiness 
following the hemorrhage; (2) partly to the low position of the placental site,. 
it thus being more exposed to external influences; and (3) lastly to the manual 
or instrumental interference at the placental site that may have been found 
necessary during delivery. 

The less the bleeding is accompanied by uterine contractions, the graver 
is the prognosis, since labor pains always tend to close the mouths of the blood- 
vessels. Lastly, the greater the anemia that is brought about before actual 

labor, the greater the risk; 
since some operation may 
be demanded to hasten de- 
livery which the woman in 
her weakened condition is 
little able to bear. There 
is more hope of saving the 
child than many authors, 
admit, and this fact should 
be kept constantly in mind. 
In early gestation the cause 
of fetal death is placental 
apoplexy followed by pain- 
less abortion. In these cases 
the ovum is usually expelled 
entire (Fig. 275). Later on, 
after the child has become 
viable, the chief danger is 
asphyxia from the loss of 
maternal blood as a con- 
sequence of separation of 
the placenta. Other causes 
of fetal mortality are (1) 
malposition, the placenta 
in the lower uterine seg- 
ment not allowing the head 
to present, the shape of the 
uterus also being distorted; 
(2) premature delivery 
found necessary to save the 
mother's life, and (3) ver- 
sion, which in many cases 
is performed to control hem- 
orrhage or to effect speedy delivery. Hemorrhage and inanition may also be 
causes of fetal death. Malpresentation frequently occurs owing to the relaxed 
condition of the uterus and the softening and stretching of the lower uterine 
segment, and to the fact that the placenta usually occupies the space filled 
by the presenting part. M tiller found in 1148 cases 272 transverse presen- 
tations and 107 breech presentations. Premature labor and premature rup- 
ture of the membranes are common in this condition. In our 9 cases of 
placenta praevia already cited, there was one maternal death, due to rupture 
of the uterus from rapid manual dilatation of the cervix. The maternal 
mortality was 11. 11 per cent.; the fetal mortality, 22.23 per cent. Of the 




Fig. 275. — Partial Placenta Previa at Four and 
a Half Months. Spontaneous expulsion of an un- 



ruptured ovum with moderate hemorrhage. - 
collection.) 



(Author's 



ANOMALIES AND DISEASES OF THE PLACENTA. 



231 



9 cases, 4 were treated by manual dilatation of the cervix followed by 
immediate version and extraction; 2 by podalic version; 1 by manual dila- 
tation and forceps, and 1 by spontaneous delivery. 

Summary of Prognosis: The causes of the great maternal mortality are (1) 
hemorrhage; (2) septicemia; (3) inflammations — metritis, peritonitis, phle- 
bitis; (4) shock of version, which operation is generally indicated, and is, in 




Fig. 276. — Central Placenta Previa at the Sixteenth Week. Sudden and spontaneous 
hemorrhage and death within six hours from acute anemia. Blood loss estimated at 
several pints. Placenta membranacea is also present. The membranes are un- 
ruptured. (£ natural size.) — (Author's collection.) 



many cases, performed when the woman is in an exhausted state from the 
loss of blood or previous attempts at delivery through an imperfectly dilated 
os. The causes of fetal mortality are (1) asphyxia; (2) prematurity; (3) version; 
(4) malpresentations ; (5) inspiration pneumonia. 

Treatment. — Prophylaxis. — Not much can be said under this head. Women 
with endometritis should not conceive; not only placenta prsevia, but other 
anomalies of pregnancy and labor, originate from this affection. If a woman 



232 PATHOLOGICAL PREGNANCY. 

with well-marked endometritis should become pregnant, the question of inter- 
ruption of pregnancy might be considered. 

Treatment Proper. — The first point to consider when notable hemorrhage 
occurs is the distinction which must often be made between suspected and 
known placenta praevia. This diagnosis cannot be made unless the os is patent, 
and to open the os will induce labor. The hemorrhage must be checked, 
and major hemostatic procedures will also induce labor. It would be unwise 
to remain in ignorance of the true state of affairs ; the bleeding must be arrested ; 
and the treatment for detachment of a normally seated placenta — between 
which affection and placenta praevia the diagnosis lies — is to empty the uterus. 
Hence, in suspected placenta praevia the rule is to induce labor, for while we 
may sometimes temporize in this affection it is never allowable in premature 
detachment. The diagnosis can be made only by dilating the cervix, and if 
we then recognize the presence of placenta praevia it is too late to temporize 
and labor must proceed. If the suspicion of placenta praevia come from slight 
hemorrhage, it would not be justifiable to dilate the os for the purpose of diag- 
nosis unless the bleeding were very persistent. Milder hemostatic procedures 
should first be tried. The management should then be that of threatened 
abortion or premature labor. (See Abortion.) When the diagnosis of placenta 
praevia is assured, the broad rule is to empty the uterus at once. This is at 
least the theoretical aspect of the question. In practice, however, numerous 
conditions assert themselves which constitute exceptions. A certain number, 
probably constantly decreasing, of practitioners regard intervention before 
the seventh month as meddlesome. Statistics show that fatal hemorrhage 
before this period is rare. Fig. 276 is a specimen in my collection from a 
woman pregnant at the sixteenth week, with placenta praevia, who died of 
uterine hemorrhage and acute anemia within six "hours after the appearance 
of the first bleeding. The blood loss was estimated at several pints. The 
minority, who dissent from the routine practice of emptying the uterus at all 
times, hold that the interruption of pregnancy before viability is unnecessary, 
unless for special indication, such as profuse hemorrhage. They claim also 
that if the mother is in no danger, the fetus should be given a chance of sur- 
vival. The majority, on the other hand, maintain that the mother is always 
liable to a fatal hemorrhage; that moderate loss of blood up to the time of 
viability produces a weakening effect on the mother; and, finally, that the 
chances of the fetus for survival are so slight that they should be disregarded. 
To the dissent of a portion of the profession must be added the scruples of the 
prospective mother and her relatives. The idea of terminating the pregnancy 
without regard to the right of the issue may be repugnant, and an heir may 
be greatly desired for more reasons than one. The mother, too, may be willing 
to accept the risk. In such a case the most the practitioner can do is to 
explain the dangers as fully as possible, and perhaps to call a consultation; the 
joint opinion of two practitioners should go far toward persuading the woman 
to choose the wise course. There are also other circumstances to be considered. 
Even if it were decided to induce labor-? reasons for delay might occur, especially 
in rural practice. 

Expectant Treatment. — If the condition is recognized before the seventh 
month, and the aim is to continue the pregnancy, the woman must be made 
to lead a quiet life, mentally and physically. She should, as far as possible, 
avoid all muscular effort, such as straining at stool. Coitus should be interdicted. 
The diet should be light. If moderate hemorrhage is present, she should 
lie in bed till all bleeding ceases. For uterine contractions opiates should be 



ANOMALIES AND DISEASES OF THE PLACENTA. 233 

given. If the symptoms are more severe, the patient should be placed upon 
the full regimen for threatened abortion. The foot of the bed should be raised 
and cold applications made to the pelvis. Some authors recommend hot 
styptic douches (acetic acid), but this is almost certain to induce labor. If 
the hemorrhage is of such severe type as to require such means to check it, 
the time for temporizing is doubtless past. The expectant method requires 
the constant presence of an attendant who is able to deal with a profuse 
hemorrhage should such occur. 

Treatment of Hemorrhage. — The milder degrees of hemorrhage have been 
considered under the expectant management. The severe grades — flooding — 
may or may not originate from the onset of labor. In the spurious or lateral 
variety of placenta praevia hemorrhage coincides with the first attempts at 
dilatation of the os; but in the true or central form the escape of blood is in 
nowise dependent upon uterine contraction. Therefore the management of 
flooding should receive separate consideration. The treatment of these severe 
hemorrhages is of a character to bring on labor. It cannot be said that this 
is a desideratum, for no practitioner would wish to see a woman who has just 
been depleted by a loss of blood pass immediately into a condition of labor. 
Unfortunately there is no manner by which these hemorrhages can be arrested 
save by dilating and plugging the cervix, which necessarily provokes labor. 
Attempts at securing hemostasis by measures directed to the vagina alone 
(tampons, kolpeurysis, etc.) have been largely abandoned as irrational. Of 
possible service in mild cases, they are worthless in flooding. The tamponade 
is further a source of infection, and when thoroughly performed is very painful. 
Despite these drawbacks, many conservative practitioners continue to employ 
tampons. Some authorities concede their usefulness if the cervix is included 
in the packing. Many see an indication for a simple vaginal tamponade in 
all hemorrhages with closed os. Plugging the cervix is regarded as the more 
rational treatment for hemorrhage. This is effected by hydrostatic bags or 
by gauze in connection with vaginal tamponade. Profuse hemorrhage often 
subsides spontaneously. 

Management of Labor with Placenta Praevia. — The fact that rational attempts 
to arrest flooding tend to induce labor brings us naturally to the subject of 
parturition itself, which may be considered under two heads: viz., spontaneous 
and induced. 

Spontaneous Labor. — When all the circumstances are favorable, natural 
labor is possible in placenta praevia. I have seen several such cases. Among 
these propitious uterine conditions are included good uterine action, rare in 
this affection; more or less separation of the placenta, with resulting coagu- 
lation and prevention of hemorrhage; and normal presentation. Another form 
of natural spontaneous delivery is seen when the placenta is born before the 
child (Fig. 275). With the exception of the latter variety, when the placenta 
is centrally seated, natural labors occur mostly with placentae of lateral 
insertion. The management of these spontaneous labors hardly varies from 
that of normal pregnancy. If inertia arise, the forceps may be applied or 
version performed. The use of forceps is slightlv more favorable to the 
child. 

Induced Labor. — Labor may be induced deliberately in placenta praevia as 
soon as the diagnosis is made, or it may be brought about by efforts to check 
or prevent hemorrhage. The simplest condition for induced labor is found 
in placenta praevia lateralis. Here, as a rule, the uterine action is good, and 
the hemorrhage always due to the action of the first labor pains in dilating 



234 



PATHOLOGICAL PREGNANCY. 



the cervix. If the membranes are ruptured prematurely, allowing the water 
to escape, the presenting part presses upon the lower segment and arrests the 
hemorrhage. Rupture of the membranes naturally delays labor instead of 
expediting it, and some inertia may develop. If this occur, the forceps should be 

applied in conjunction with 
external manipulation of the 
uterus, the latter being de- 
signed to prevent an atonic 
state and post-partum hemor- 
rhage. In induced labor, 
aside from the exception just 
given, three indications must 
be met: viz., (i) rapid dilata- 
tion, (2) hemostasis, and (3) 
the abbreviation of the ex- 
pulsive period. If for any 
reason rapid dilatation can- 
not be practised, the cervix 
and vagina must be tam- 
poned and the opening of 
the cervix left to nature. 
Before proceeding with rapid 
dilatation it is customary to 
detach the placenta from the 
lower segment as far as the 
fingers will reach. This is 
followed by coagulation of 
the blood of the denuded sur- 
face. In regard to the indi- 
cation for shortening labor, 
and at the same time secur- 
ing hemostasis, the Braxton- 
Hicks method of bipolar ver- 
sion is recommended by some 
authorities as an ideal pro- 
cedure. This method causes 
an overlapping of the first 
two stages of labor, a leg 
being extracted before the 
os is fully dilated, serving as 
a dilator and hemostatic. (See 
Bipolar Version.) The usual 
method of accelerating and 
terminating labor in placenta 
praevia is ordinary podalic 
version. Statistics show that 
more children are delivered 
thus than by any other single method — perhaps more than all others combined. 
Delivery by version can be effected through the placenta. The chief use of the 
forceps is in cases of lateral insertion. 

Cervical and Vaginal Gauze Tamponade (Fig. 278). — The tampon is of 
service before the dilatation of the os, and if the os is rigid and the cervical canal 




internal Os 



xternal Os 



Bladder. 



Fig. 277. — Frozen Section of a Case of Central 
Placenta Previa in which One Leg Has Been 
Brought Down According to Braxton-Hicks's 
Method and the Half-breech Used as a Tampon 
to Plug the Lower Uterine Segment and the 
Cervical Canal. — (Leopold.) 



ANOMALIES AND DISEASES OF THE PLACENTA. 



235 



not easy to penetrate, and in the event of hemorrhage. If hemorrhage is present, 
it must be arrested. There is great art in inserting the vaginal tampon. The 
cervical canal should be packed first, then the vaginal roof , and, gradually con- 
tinuing down, the vagina itself is entirely filled. This whole cavity will require 
much more material to fill it than would be supposed by the tyro. Different 
physicians use various materials, — creolin gauze, plain sterile gauze, iodoform 
gauze, gauze soaked in boric-acid solution or corrosive-sublimate solution. 
The tampon not only arrests bleeding, but assists in the induction of labor. The 
strength of the patient is preserved and time is gained for the further procedure. 
It has been objected (i) that the tampon does not stop hemorrhage and that 




Fig. 2 78. — Vaginal and Cervical Tampon in Central Placenta Previa. 
sterile gauze used for the tampon and a T-bandage applied. 



Four-inch 



(2) it is prone to cause sepsis. The first objection rests upon the fact that 
tamponing is seldom well done. Auvard states that it takes 53 ounces (1500 
grams) of gauze properly to fill the vagina.* The patient should be placed 
in the Sims position, so that atmospheric pressure may dilate the cavity as far 
as possible. A speculum is then inserted and the plugging accomplished. 
There is no likelihood of internal pressure on account of the counter-pressure 
of the fetal presenting part and the bag of waters. The physician should now 
allow nothing to take him from the patient till her delivery is accomplished. 
The risk of sepsis is slight if proper precautions are taken. The vaginal tampon 
is therefore of great service (1) when there is severe hemorrhage in pregnancy; 
* About thirty to forty yards of four-inch moist gauze. 



236 PATHOLOGICAL PREGNANCY. 

(2) when there is limited hemorrhage at the beginning of labor; (3) when the 
patient can be carefully watched. Tarnier was very partial to the tampon treat- 
ment. 

Hydrostatic Cervical Bags. — The cervical hydrostatic tampons are Barnes's 
bags, Braun's colpeurynter, and the balloon of Champetier de Ribes. The 
consensus of opinion seems to incline to the last as being the most effective. 
(See Operations.) Its shape is perfectly adapted to controlling hemorrhage and 
also permits its expulsion. It is inelastic. In reality it forms a rival to the 
Braxton-Hicks method of combined version. Cervical tamponment is looked 
upon with far greater favor than the vaginal method and is indicated when 
the cervix is moderately dilated. The contraindications are (1) when dilata- 
tion is almost or quite complete; (2) when it does not arrest hemorrhage, even 
though very slight. 

Rupture of the Membranes. — There have been widely diverse views held 
by equally good authorities on this subject. After weighing carefully the 
advantages and disadvantages of this method, the following conclusions may 
be drawn: There should be early rupture of the membranes (1) in case the 
tampon does not stop an excessive hemorrhage; (2) when there are no pains, 
for the evacuation of the liquor amnii will excite the uterus to action. Rupture 
of the membranes should be deferred till late in labor (1) in case the os is widely 
enough dilated to admit of prompt spontaneous delivery, or, (2) if manual 
or instrumental delivery is easy of accomplishment. Rupture of the mem- 
branes is contraindicated (1) when the uterine contractions are vigorous but 
the os is not dilated; (2) when faulty presentation exists, unless it is possible 
to perform immediate version. 

Version. — Version is indicated (1) when the os is sufficiently dilated to 
admit two fingers and the Braxton-Hicks method of combined version can be 
easily accomplished (see Operations) (Fig. 277). No other method of version at 
an early stage is either practicable or safe. In case this operation cannot be 
readily completed, then it should be sedulously avoided and the use of the 
tampon (cervical) substituted. (2) When dilatation of the os is complete or 
almost so in the presence of copious hemorrhage, direct internal — the ordinary 
podalic — version may be resorted to. If in the early stages hemorrhage has 
been successfully avoided till the os is in favorable condition for delivery, 
this method is the most rapid, effective, and practical. In case the placenta is 
centrally implanted the operator's hand should bore right through it and then 
perform the version. (3) When the case is desperate, accouchement force is in 
order. This term has had so many significations that it is necessary to define 
it closely to avoid misunderstanding. Two circumstances to be taken into 
consideration are the degree of force necessary in this method, and the time 
of its performance. (See Part X.) In case it is apt to be attended by laceration 
of the cervix when the os is rigid and other better methods are at hand, it is, 
of course, contraindicated. It is only when immediate operation is imperative, 
when the hemorrhage is uncontrollable, that such a proceeding should be 
undertaken. But in case of a yielding cervix this method offers very brilliant 
results. The fingers and hand are really the best dilators and tampon. 
When circumstances are favorable, it is the most rapid method, but 
should not be performed unless labor has continued for some time. The 
children are often premature, and when asphyxiated should be resuscitated in 
the most gentle manner, as more energetic treatment is apt to be fatal to 
them. Version is contraindicated (1) when it cannot be skilfully performed 
with a moderately dilated os (cervical tampon); (2) when after rupture of 



ANOMALIES AND DISEASES OF THE PLACENTA. 237 

the membranes, with the os well dilated, the head promptly engages in the 
cervix. 

Management of the Third Stage. — Manual removal of the placenta is necessary 
only when after delivery the hemorrhage still persists. Sometimes bleeding 
continues after the placenta is born, and even when the uterus is well con- 
tracted. In this variety of post-partum hemorrhage the management does 
not differ from that of the ordinary forms. (See Post-partum Hemorrhage.) 
It should be remembered that the low situation of the placental site predisposes 
post partum to hemorrhage and sepsis. As a prophylaxis against the former, 
especially after much blood loss prior to and during labor, the application 
of the uterine and vaginal gauze tampon is of great service. 

After -treatment. — All danger is not over after expulsion of the placenta. 
The patient may be threatened with fatal syncope and must be kept recumbent 
with head low. If the indications arise, she should be given alcoholic stimu- 
lants by the mouth, and ether or caffeine hypodermically, with saline infusion. 
Vomiting, which is common after placenta prasvia, should be met with cracked 
ice, and, if necessary, nutrient enemata. 

Resume. — (i) Before the twenty-eighth week it is justifiable to temporize 
in exceptional cases only. (2) After the twenty-eighth week: (a) If labor is 
not present and hemorrhage is absent or moderate, labor should be induced 
with a solid bougie combined with gauze packing of the lower uterine seg- 
ment, cervix, and vagina (Fig. 278). As soon as the cervical canal has dis- 
appeared, dilatation is to be carefully completed by the bimanual method, 
combined, if necessary, with Braxton- Hicks 's bipolar version, to control hem- 
orrhage. Some authorities prefer Barnes's or Champetier's bags for completing 
dilatation. I have abandoned their use. The second stage should be short- 
ened by forceps or version, preference being given to the former, or, if Hicks 's 
hemostatic method has already been performed, by breech extraction. A 
case should never be left to natural expulsion after version has been per- 
formed. (6) If the patient is in collapse, with an un dilated os, it is necessary to 
tampon the lower uterine segment, cervix, and vagina, and to wait until reaction 
has been secured by infusion, stimulants, or nutrient enemata, before completing 
delivery, (c) If the patient is in good condition, with os dilated or dilatable, 
the membranes should be ruptured and the second stage shortened with the 
forceps. In the absence of marked hemorrhage and in the presence of good 
uterine contractions spontaneous labor may be permitted to proceed, the case 
to be constantly watched for internal or external hemorrhage, (d) In the case 
of a dilated or dilatable os and a collapsed patient it is justifiable partially to 
detach the placenta from the zone of dangerous attachment, or even entirely to 
detach and deliver it, tightly to tampon the lower segment and vagina, and 
to rally the patient before proceeding to the delivery of the child. 

2. Injuries. — Premature Detachment of a Normally Situated Pla- 
centa. Accidental Hemorrhage. — Definition. — Accidental hemorrhage is 
generally understood to mean one which occurs from the separation of a nor- 
mally situated placenta, in contradistinction to the unavoidable hemorrhage 
of placenta prsevia. These terms may be considered misnomers, as not infre- 
quently the etiology is almost the same. The separation may be partial or 
complete, the former variety being far more common. It is one of the gravest 
conditions met with in obstetrics. Clinically there are two classes, those in 
which contractions of the uterus are present, and those in which they are absent. 
Quite recently Holmes, of Chicago, has published a thesis * based upon the 
* "American Journal of Obstetrics," vol. xliv, 1900. 



238 



PATHOLOGICAL PREGNANCY. 



analysis of 200 cases from literature. He advocates the use of a new name 
for this condition: viz., ablatio placenta. He claims that the latter occurs 
much more frequently than has been believed, and that much of the current 
teaching upon this subject is false because earlier studies have been based 
on analyses of scattered reports which were not fairly representative. 

Frequency. — According to Holmes, the ratio of ablatio placentae to normal 
labor must be re-stated. In clinics where some effort has been made to recog- 
nize and record the existence of this complication something like 1 : 200 appears 
to be the prevailing proportion. As a matter of fact, however, ablatio placentae 

appears to go unrecorded 
in maternities with vast 
material. 

Varieties. — There are two 
ways in which this hemor- 
rhage may declare itself: it 
may be frank or open, or 
hidden or concealed (Fig. 
279); the former being the 
more usual, while now and 
then the two forms are 
present in the same case. 
The point of separation of 
the placenta in the first 
instance is generally at its 
lower part and the blood 
then easily ' trickles down 
between the chorion and 
the decidual and finds its 
way out through the vul- 
var orifice. In the con- 
cealed variety the detach- 
ment may take place at 
the center of the placenta, 
its connection around the 
entire periphery being at 
first perfect. In this case 
there would be formed a 
large clot behind the pla- 
centa. Or the separation 
may take place at the top 
of the placenta, in which 
case, as well as in the last, 
the hemorrhage would be to a certain extent limited. Then, again, the mem- 
branes may have ruptured and the orifice of escape may be blocked by the 
presenting part or by some of the appendages of the fetus or by a large 
blood-clot. 

Etiology. — The causes of premature detachment of a normally situated 
placenta are the evident and the obscure, — more often the latter, — and they are 
also predisposing and exciting. 

Among the predisposing causes are profound anemia, general ill health with 
great debility, persistent pelvic congestion from any cause, prolonged gesta- 
tion, multiparity, and the loose attachment of the placenta which is normal 




Fig. 279. — Internal Concealed Hemorrhage from 
Entire Separation of a Normally Situated Pla- 
centa. Internal Concealed "Accidental" Hem- 
orrhage. — (Modified from Winter.) 



ANOMALIES AND DISEASES OF THE PLACENTA. 239 

in the last two months of gestation and depends upon the fatty changes going 
on as preparatory to labor. Thus, we rarely see accidental hemorrhage until 
the last few weeks or at the onset of labor, and seldom in primigravidce. It 
is questionable whether this hemorrhage can ever occur with a healthy pla- 
centa and uterus; some diseased condition, as syphilis, uterine or peri-uterine 
inflammation, or nephritis, is necessary as a predisposing cause. The observa- 
tions of many point to a close connection between nephritis and this hemorrhage, 
the apoplexies and degenerative changes of the decidua and placenta favoring 
the hemorrhage.* 

Veit believes that the presence of endometritis is necessary to explain acci- 
dental hemorrhage in kidney disease. He believes that the most important 
cause of this complication is disease of the decidua? . Various diseases of the 
decidua and placenta have been found in accidental hemorrhage. 

Among the exciting causes is traumatism of various kinds, direct and indirect, 
received either externally or from violent muscular efforts on the part of the 
patient. This cause cannot be denied, although it is ignored by some authorities. 
Under hill reports a case due to direct traumatism, and the author has observed a 
case in which a woman pregnant at the eighth month, while hanging clothes from 
the fire-escape of a tenement-house, leaned heavily with her abdomen against 
the iron railing. Faintness and profuse uterine hemorrhage occurred imme- 
diately, followed shortly by labor and the delivery of a dead fetus and several 
large blood-clots. The placenta was situated above the lower segment. 

Hemorrhage from traumatism does not always follow the shock. In a 
case of the author's it was delayed several days. This is in accordance with 
the observations of Kiwisch, who states that hours or days may elapse between 
the two events. Again, hemorrhage may occur when the patient is in repose 
or even when she is asleep. This accident has also followed indirect trauma- 
tism, as slipping on ice, lifting heavy weights, vomiting, coughing, concussion, 
jolting, etc., by which probably some of the placental attachments were lacer- 
ated. Profound emotion has been given as an exciting cause by Barnes, f by 
causing sudden alteration in the equilibrium of the utero-placental circulation. 
A marked predisposition is undoubtedly present in these cases. A very short 
cord has sometimes proved to be the cause of this accident, especially if the 
fetus be vigorous. In hydramnios, in which the volume of the uterus is 
quickly diminished by the escape of a large bulk of liquid; or in twin deliv- 
eries, after the birth of one child, the subsequent contraction may cause 
placental detachment with fatal hemorrhage. Sligh's case % illustrates both 
of these conditions, as well as the necessity for instantaneous action in com- 
plications of this kind. 

Certain cases have been reported in which the uterus was abnormal; in one 
case there was present vagina duplex, and the uterus also shared in the abnor- 
mality. Other cases have shown a condition of uterus bicornis with one 
horn rudimentary. If the placenta is attached to the latter, and should 
this horn contract while the rest of the uterus remains passive, the placenta 
may become prematurely separated. That this phenomenon does take place 
has been clearly proved. Holmes sums up the predisposing causes of the 
material which he analyzed as follows : Endometritis comes first in order ; then 
follow general conditions which predispose to hemorrhage, such as renal lesions, 

* O. Von Weis: "Archiv f. Gynak.," Bd. xlvi, H. 2, 1893. 

t "System of Obstetrics," page 582. 

% "American Journal of Obstetrics," 1892. 



240 PATHOLOGICAL PREGNANCY. 

albuminuria, arteriosclerosis, diseases of the placenta, tumors of the uterus, 
etc. Endometritis, however, appears to co-operate in many of these cases as 
well. 

Symptoms and Diagnosis. — In the external form the escape of blood 
is noticed, and at once points to the existing condition. The problem in the 
case of the concealed variety is often obscure. In certain cases marginal 
separation does not occur, and the escaping blood is collected between the 
uterus and placenta, where it forms clots which are retained in this situation 
(Fig. 286). More commonly, however, separation of the placental margin 
does occur, and there forms a collection of blood between the wall of the uterus 
and the membranes. This may be either in the region of the fundus or near 
the cervix. In the latter situation the blood may be prevented from escaping 
by the pressure of the presenting fetal part. In this case the coagula are 
prone to cause much pain from the distention and stretching of the uterine 
muscle. Besides the appearance of blood in the frank variety, there is generally 
pain, which is at times persistent and of a tearing, piercing character or 
cramp-like, colicky, and bearing-down. The suffering varies greatly in dif- 
ferent cases. Pain may be localized at the placental region or at the lower 
uterine segment, due to stretching from retained clots. Instead of a sudden 
gush of blood, there may be a more or less continuous dripping, part escaping 
and part coagulating. This condition may continue for weeks. 

The symptoms of the concealed form are chiefly extreme collapse and ex- 
haustion with no apparent cause. In case of extreme internal hemorrhage 
with slight external escape, the diagnosis may be made by the fact that the 
constitutional symptoms are so much more severe than the amount of blood 
visible would be likely to account for. Shock may exist even when there is 
no great loss of blood; it is then due to enormous distention of the uterus. 
Besides the pain already referred to, which may be agonizing, there may 
be observed an irregularity in the form of the uterus, caused by the massed 
coagula. This is not easy to make out, except, perhaps, in the case of a patient 
who is thin and who has very lax abdominal walls. A rapid increase in the 
size of the uterus may be noticed. There may be a complete absence of labor 
pains, and if they are present they are usually slight and insufficient. There 
is extreme pallor, the body surface is covered with drops of perspiration, and 
the extremities are cold and clammy. The pulse is small, compressible, and 
rapid; dyspnea and "air-hunger " are present; the patient suffers from thirst, 
nausea, disturbances of sight and hearing; then ensue jactitation, coma, and 
death. Differential diagnosis should be made from ordinary syncope in that 
the symptoms in concealed hemorrhage are more severe and persistent. 

Holmes's analysis shows that hemorrhage is rather untrustworthy as a guide 
in frankly hemorrhagic cases. Complete detachment has occurred without 
any escape of blood; therefore we must estimate all the possible evidences 
of concealed hemorrhage (shock, acute anemia, tumor, etc.) before making a 
diagnosis. Escape of blood-serum by the vagina is a symptom of great sig- 
nificance as indicating the persistence of clots within the uterus. The pres- 
ence of dark blood or clots accompanying the expelled fetus or placenta is also 
pathognomonic of a past ablatio placentas. 

Differential Diagnosis. — Placenta prcevia can be differentiated from acci- 
dental hemorrhage only by actually palpating the placenta in the former, 
although the latter condition is apt to occur in the first stage of labor, to be 
attended by sharp pains, and to persist until the uterus is evacuated or the 
patient dies. No deviations from the conditions of normal pregnancy are 



ANOMALIES AND DISEASES OF THE PLACENTA. 241 

revealed by vaginal examination in accidental hemorrhage. This statement 
must be slightly modified, as in the concealed variety vaginal examination 
may show a prominence of the vaginal part of the uterus. It is as if it were 
being pressed down into the vagina from above, while the presenting part is 
often well above the pelvic brim. Rupture of the uterus follows a protracted 
or obstructed labor or operation. There are previous thinning of the lower 
uterine segment shown above the pubis, recession of the presenting part, and 
diminution of the uterine tumor; the membranes have usually ruptured; escape 
of the fetus into the abdominal cavity may be observed, giving two abdominal 
tumors. It is easy to exclude lacerations of the cervix by palpation and 
inspection. A ruptured extrauterine pregnancy must also be taken into con- 
sideration. The history of the case should be investigated. Abnormal pains, 
changes in the fetal heart sounds, alterations in the outlines of the uterus, 
symptoms of the hemorrhage, and the condition of the vaginal part of the 
uterus afford the chief differential points. 

Physical Signs. — In the frank form the cervix is normal and the uterus, 
for its condition, not increased in size; but it is more or less flabby and good 
contractions cannot be induced. Vaginal examination reveals escaping blood 
and the absence of a placenta praevia. 

In the concealed variety, however, the uterus is observed, by abdominal 
palpation, to be rapidly enlarging; there is slight contraction about the fundus, 
and at times the lateral uterine walls are bulged; the fetal parts are made 
out with increasing difficulty; and the fetal heart sounds are invariably altered, 
and, in detachment of any extent, are entirely absent. In case of retro- 
placental hemorrhage there may be a swelling on that side of the uterus while 
the rest of the organ is contracted. 

Prognosis. — When there is an external flow of blood, the prognosis for the 
mother is not very unfavorable, since the condition may be readily recognized 
and treated. Speedy termination of pregnancy will check the bleeding and 
save the patient's life. The shock is not so great, for the uterus is not so dis- 
tended; and the separation of the placenta is frequently incomplete. About 
85 per cent, of the children are born dead. In the concealed form, however, 
there is far more danger, and here the mortality is great, for often the diagnosis 
is not made until the patient is nearly moribund. Of Goodell's 106 cases, 
54 mothers died — 51 per cent. 

Other factors influencing this great mortality are the constitution of the 
patient, which is generally feeble and diseased, and the shock from overdis- 
tention. The very fact, too, of OA^erdistention indicates loss of contractility 
of the uterine musculature. The nearer the completion of the second stage, 
and the more readily the cervix is dilated naturally or artificially, the 
better the outlook. In pregnancy the chances for fetus and mother are better 
in multiparas than in primiparae, on account of the ease with which the os can 
be dilated in the former. 

For the child, the prognosis is even worse. Of 107 children, of Goodell's 
cases, 6 only were born alive — 94 per cent, mortality. This is probably ex- 
plained by the fact that when blood collects between the placenta and the uterus, 
the fetal part of the former is probably torn and the child dies from hemor- 
rhage. Other causes of fetal death are prematurity and asphyxiation from 
interference with the function of the placenta. The maternal mortality 
in Holmes's series of cases is considerably lower than that commonly admitted — 
32.2 percent.; his child mortality (85.8 per cent.) is slightly better than that here- 
tofore taught. The death-rates (maternal) for concealed and open hemorrhages 
16 



242 PATHOLOGICAL PREGNANCY. 

were 23 and 34.6 per cent, respectively. It is difficult to formulate special 
prognostic indications. 

Treatment. — If the hemorrhage takes place during pregnancy and is not 
severe, the treatment should be parallel with that of threatened miscarriage. 
Or, even if the hemorrhage has been large but has entirely ceased, the uterus 
need not be interfered with. The treatment should then be preventive and 
protective. These patients should always be carefully watched. It may be 
that a living child will be born at term. 

In the presence of severe hemorrhage the two indications are (1) to secure 
tonic and continuous uterine contraction and (2) the emptying of the uterus 
as rapidly as is consistent with the safety of the mother. I believe the first 
indication is most surely obtained by ( 1 ) artificial rupture of the membranes, (2) 
massage and manual compression of the uterus, and (3) the repeated hypo- 
dermatic injections of ergot (tt^xxx of the tincture every fifteen minutes for 
three or four doses). The speedy delivery can be accomplished by rapid instru- 
mental and digital dilatation of the cervix and the use of forceps, version, or 
perforation according to indication. Deep incisions of the cervix are occa- 
sionally useful. 

The choice between version and the forceps operation will depend upon 
which can be most rapidly performed in the individual case. If the head has 
passed the pelvic brim, which is not usually the case, a forceps operation is 
of course indicated. In either case the operator should work rapidly, remem- 
bering that the danger to the mother from moderate lacerations of the birth 
canal is insignificant compared to the danger of hemorrhage from an uncon- 
tracted uterus. 

The most efficient check to hemorrhage is uterine contraction, which must 
be brought about if possible. By rupture of the membranes, the liquor amnii 
will escape and the uterine contraction will take place. If the loss of blood is 
very small, it may be that rupture of the membranes will be the only artificial 
step necessary, and the rest will be looked after by nature, though early rupture 
of the membranes delays labor. In severe cases the mother's safety alone 
should be considered, for the death of the child is reasonably certain. 

In order to strengthen the pressure on the cervix and to prevent a collection 
of blood at the fundus, the patient should be kept in bed and on her back. 
In the milder forms, vaginal plugging, massaging the uterus, with general 
stimulation, should be used till the cervix is sufficiently dilated to allow of 
delivery. Tampons must not be used after rupture of the membranes. A 
firm abdominal binder should be applied to prevent any internal collection 
of blood from forming. Uterine compression and the administration of ergot 
will further contractions, as will the application of an ice-bag over the sus- 
pected place of hemorrhage. Cold may be applied by atomizing ether over 
the abdomen. If the hemorrhage does not cease, or if concealed hemorrhage 
is suspected, the uterus must be emptied. During the progress of labor and 
delivery the uterus should be carefully followed down by an assistant, and 
after delivery every effort should be made to secure and maintain uterine con- 
traction. (See Expression of Fetus, Part X.) 

Perforation may be indicated if the child is dead or non-viable, or if the fetal 
head is large or the maternal pelvis very small, or the hemorrhage so severe 
as to endanger the mother's life. Csesarean section should be considered in ex- 
treme cases. If the patient is in collapse, it may be best to revive her by 
warmth and stimulants before operative proceedings are begun. The after- 
treatment consists in the prevention, if possible, of post-partum hemorrhage. 



ANOMALIES AND DISEASES OF THE PLACENTA. 



243 



When much blood has been lost, the resulting anemia must be promptly 
treated by hypodermoclysis of decinormal saline solution, with rectal and intra- 
venous injection as well. There have been no recent advances made in the 
therapeutics of this affection, which is, therefore, still unsatisfactory. 

3. Stasis, Passive Congestion, and (Edema. — Obstruction of the return cir- 
culation of the placenta gives rise to a characteristic state of that organ. 
Through the resulting cedematous saturation, the size of the latter may undergo 
a fourfold increase. It becomes pale and friable, and hence easily disintegrated 
during expulsion, with retention of certain portions. As in the case of oedema 
elsewhere, stasis may not be the sole efficient cause, for a hydremic quality of 
the blood incidental to the underlying state of the patient may co-operate. 
Stasis and oedema of the placenta have been encountered in cardiac disease 
(so-called cardiac placenta), renal disease, and other maternal conditions. 
More commonly, however, the 

causes are to be sought in hy- 
dramnios or some obstruction in 
the circulation of the fetus. The 
latter class includes syphilitic ob- 
struction of the umbilical vein 
(Fig. 284), and disease of the fetal 
heart, liver, and kidneys. Finally, 
in general fetal anasarca the pla- 
centa may be cedematous. When 
the fetus is responsible for the 
oedema, the fetal portion of the 
placenta is chiefly involved. 

4. Interstitial Hemorrhage (Ap- 
oplexy, Infarction, Hematoma, 
Thrombosis). — The effusion of 
blood is not necessarily inter- 
stitial, for it may be between the 
chorion and placenta, in the form 
of a large clot, over the whole 
external chorionic surface; or it 
may represent a utero-placental 
hemorrhage (Fig. 286). The first 
occurs during the first three 
months of pregnancy, before com- 
plete union of the chorion and 

decidua; after the third month, this union prevents effusion beyond the limits 
of the placenta. Hence during the greater portion of pregnancy the hemor- 
rhage is apoplectic and sharply distinguishable from accidental and inevit- 
able placental hemorrhages (Figs. 280, 281, 282, and 283). 

Pathology. — It is in the early months that hemorrhage more commonly 
occurs from true apoplexy, which consists in the rupture of the fragile maternal 
capillaries surrounding the villi. Later on in pregnancy, the cause is more 
often thrombosis in the sinuses, or rupture of the fine blood-vessels which 
enter the placental sinuses after penetrating the upper layer of the decidua 
serotina. These masses of coagulated blood, in their several stages of degen- 
eration, constitute placental hematomata. These formations undergo the 
usual retrogressive metamorphoses. ' (1) The form of the fresh clot is most 
common when abortion has resulted from the hemorrhage. (2) The extrav- 




Fig. 280. — Hemorrhages into the Pla- 
centa Caused by Albuminuria. — (Ribe- 
mont-Lepage.) 



244 



PATHOLOGICAL PREGNANCY. 



asated blood may be walled off by a fibrous envelope, more or less thick, 
and may consist of reddish or brownish liquid, or even clear serum, while the 
blood coloring-matter is collected upon the cyst-wall or the neighboring villi. 
(3) The liquid may contain numerous white blood-corpuscles, giving it the 
appearance of pus, and such collections have been described as "placental 
abscesses" by various writers. (4) In other cases the fibrin element may be 
in the ascendency. This condition is found particularly in certain cases of 




Fig. 281. — Microscopic Section of a Placental Infarct. — (Schaeffer.) 
1 , Decidua papillae in the chorionic placenta ; 2 , a large connective-tissue' villus in the decidual 
tissue conveying fetal blood-vessels; 3, normal villi containing fetal blood-vessels within 
the intervillous spaces, normally filled with maternal blood; here is the protoplasmic 
covering with nuclei scattered through it; 4, decidual cells separated from each other 
by exudation and undergoing necrosis; 5, necrotic villi lying in degenerated decidual 
papillae, which have become converted into laminated masses of fibrous tissue (these 
layers [6] are the result of the varying pressure of the uterus on the ovum) ; 7 , degenerated 
chorionic villi still retaining a trace of nuclear stain in the nuclei of the spindle-cells 
fused together by homogeneous masses of cell debris, formed by the fusion of the necrotic 
nucleated protoplasmic covering of the villi with secondary intervillous thrombi; 8, the 
necrotic cellular debris is undergoing organization; 9, a broad zone of connective tissue 
rich in cells is then formed; 10, fibrinous intervillous thrombus; 11, intervillous thrombus 
which has not yet undergone coagulation; 12, villus in the first stage of necrobiotic 
homogeneous coloration; the connective-tissue stroma of the villus is intact; 13, villus 
in the second stage of degeneration; the covering is changed to a feebly staining, homo- 
geneous, granular mass of debris, which becomes fused with that of the adjoining 
villus; the walls of the blood-vessels are thickened in places where the stroma of the 
villi begins to degenerate; 14, calcareous deposits; 15, minute cysts within the berry-like 
proliferations of the protoplasmic covering (16) , which at this point is peculiarly rich in 
cells; 17, deposits of calcified material within these cysts. 

thrombosis of the placental sinuses ; as in an aneurysm in the course of obliteration 
the slow coagulation of blood results in the deposition of layers of fibrin. (5) 
The serum may rapidly disappear, leaving the red blood-corpuscles in a mass, 
while the leucocytes are either distributed through the latter or collected in 
one place. (6) Still another change is the organization of the clot, by which 
a distinct neoplasm is formed, while the adjacent villi go through a fibro-fatty 
degeneration. The utero-placental hemorrhage may be recognized, after the 



ANOMALIES AXD DISEASES OF THE PLACENTA. 



245 




Fig. 2S2. — Fresh Hemorrhagic Infarct of 
the Placenta. — (Schilling.) 



expulsion of the ovum, by the characteristic appearance of the latter. It is 
fleshy in consistency, dark bluish-black in color, and has a very smooth sur- 
face. On examination the am- 
nion and chorion are found to be 
uninjured. The fetus may be ab- 
sorbed, if sufficient time has elapsed 
between its death and the expulsion 
of the ovum. If the period of time 
is shorter, the fetus wiU be seen 
floating in the liquor amnii. If, as 
the ovum is discharged, the decidua 
becomes detached, the former looks 
much like a blood-clot. It is to 
the hemorrhage into the placental 
site, after the third or fourth 
month, that Cruveilhier has ap- 
plied the term placental apoplexy. 
If the extravasation of blood 
takes place into the uterine sinuses, 
thrombosis of the placental sinuses 
is said to have taken place (Slav- 
jansky). 

Etiology. — The blood-current in the sinuses of the placenta moves very slowly 
in its course; this sluggishness, with the predominance of fibrin in the blood of 

pregnant women, causes a ten- 
dency to thrombosis. The pla- 
cental villi may be diseased. The 
heart from some cause may be 
stimulated to sudden and exces- 
sive action, which produces apo- 
plexy not only of the placenta, 
but also of the brain. Syncope 
also gives rise to a tendency to 
thrombosis. The more common 
locality of the rupture is in the 
maternal part of the placenta ; 
its cause is some pathological 
condition of the mother which 
leads to great arterial tension and 
venous congestion ; e.g., chronic 
nephritis. In this state any 
additional strain on the already 
overtaxed venous walls makes 
them rupture, with the conse- 
quent apoplexy or extravasation. 
Traumatism also may produce 
this condition; for example, a 
blow upon the abdomen. If the 
cause be of fetal origin, death 
may result from the arrested 
blood-supply. 
Symptoms . — There are no clinical symptoms characteristic of this condition. 




Fig. 2 S3. — Placental Infarct in Eclampsia 
Subamniotic Necrotic Area. — (Schaeffer.) 



246 PATHOLOGICAL PREGNANCY. 

Those following a sudden or large effusion include all the phenomena of 
shock: feeble and small pulse, cold and clammy skin, syncope, pallor, and 
uterine pain. The condition terminates in abortion. When the discharged 
ovum is examined, the cause will be apparent. 

Diagnosis. — The existence of placental apoplexy may be inferred if the 
above symptoms follow an injury to the abdomen; e. g., a blow. It can be 
positively diagnosed only after delivery, by examination of the ovum. Another 
factor leading to the detection of this affection is repeated abortions by the 
patient, from the same cause. Then, if the woman be known to have a ten- 
dency to placental apoplexy, and there occur symptoms of internal hemor- 
rhage, the same condition will be logically suspected. 

Prognosis. — The danger increases with the advance of pregnancy, and in 
the latter months it is considerable. 

Terminations. — If extensive placental detachment occurs, death of the fetus 
and miscarriage are inevitable. If separation does not occur or is limited, 
there is diminution of fetal vitality. If separation is slight in extent, it is not of 
clinical importance. The dangers to the mother are those of abortion and 
miscarriage, and possibly accidental hemorrhage, either external or concealed, 
the latter being much more serious. 

Treatment. — In severe cases the treatment is that of abortion. If the occur- 
rence of apoplexy is only suspected, the treatment must be symptomatic; we 
should prescribe concentrated saline cathartics, limited diet, and the observ- 
ance of absolute rest. 

5. Placentitis. — Inflammation of the placenta was formerly recognized as 
a legitimate affection in obstetrics. Later, its existence was disputed out- 
right, and pathological changes of alleged inflammatory nature were inter- 
preted otherwise. To-day, however, it is admitted that inflammation of the 
placenta may occur, even if very infrequently. The truth of the matter appears 
to be that with the defects of our present knowledge of the development and 
histology of the organ it is impossible to formulate a pathology which shall 
be trustworthy for non-specific affections. The best argument for the exist- 
ence of placentitis as a disease is the great number of progressive and retrogres- 
sive lesions, encountered in the organ, which are known to follow inflammation 
in other portions of the body. The principal objection to the recognition of 
the existence of placental inflammation lies in the absence of capillaries and 
nerves in the maternal portion. Placentitis may be divided into acute and 
chronic forms. (1) Acute septic placentitis: This affection is mentioned by 
authors as having been caused by. direct infection either from attempts at 
criminal abortion or from rupture of a pyosalpinx into the uterus. Pus 
forms in situ, and with the phenomena of general sepsis, abortion results. 
(2) Gonorrheal placentitis: According to Donat, the gonococcus is able to 
cause an acute purulent inflammation which extends from the decidua sero- 
tina into the fetal placenta and produces interruption of pregnancy. Von 
Franque is skeptical as to the existence of this type of disease. (3) Eman- 
uel's disease: This author has described a necrotic and purulent inflammation 
of the placenta in the lesions of which he found certain non-specific micro- 
organisms. The affection first involved the decidua and thence extended into the 
maternal placenta, causing abortion. In this connection it may be stated 
that placentae which exhibit many of the phenomena that commonly follow 
acute inflammation elsewhere (white infarcts, necrotic foci, thrombosis, etc.) 
may well have been affected by some form of bacillary disease. (4) Specific 
placentitis: Authors speak by implication of placental alterations in the acute 



ANOMALIES AND DISEASES OF THE PLACENTA. 



247 







specific infectious diseases. We have been unable to obtain any satisfactory 
account of these lesions. (5) Interstitial placentitis: This condition, which 
doubtless corresponds to the decidual and diffuse placentitis of some authors, 
is an interstitial inflammation of the maternal portion of the placenta which 
begins in the vascular trabecular. Through the changes which accompany 
chronic inflammation in general, the villi are subjected to compression and 
arrest of blood-supply. Secondary degenerative changes then ensue in the 
parenchyma of the organ, which becomes diminished in size. Firm adhesions 
may form between the placenta and the wall of the uterus. Endometritis, either 
primary or secondary, is doubtless the cause of a majority of these affections. 
Hegar and Maier once described a form of interstitial placentitis which was 
essentially a peri- arteritis. (6) Renal or albuminuric placentitis : There are no 
constant changes in the placentae of women who are suffering from albuminuria, 
but such individuals very commonly ex- 
hibit such alterations as white infarcts, 
round-cell infiltration, various degenera- 
tions, hemorrhages, fibrous hypertrophy 
of villi, endarteritis and peri-arteritis, etc. 
These lesions in turn cause defective de- 
velopment or death of the fetus, prema- 
ture delivery, premature separation of a 
normally seated placenta, and, much more 
rarely, adhesions. All these changes may 
occur without nephritis, the latter being 
only a contributory cause, acting perhaps 
indirectly through the presence of endo- 
metritis of renal origin. 

6. Infectious Granulomata. — The pla- 
cental changes in tuberculosis and syphilis 
are tolerably well known. 

(1) Tuberculosis. — Localization of this 
affection in the placenta is extremely rare, 
and is known to occur only under the fol- 
lowing conditions : In acute miliary tuber- 
culosis, as well as in the chronic form of 
the same disease which follows pulmonary 
phthisis, we sometimes encounter small 
grayish-yellow tubercles in the organ. 

They are but sparsely present. The placenta is almost immune to attack from 
Koch's bacillus. The tubercles, which are usually caseous, are scattered in 
the intervillous space — decidua, villi, stroma, etc. The blood-vessels of the 
villi exhibit obliteration as a result of endothelial proliferation. In this 
manner the fetus might be protected to a certain extent from placental infec- 
tion. The diagnosis of tuberculosis of the placenta has been verified by 
the demonstration of the bacillus and also by animal experiment. 

(2) Syphilis. — This affection is perhaps the most prolific cause of death 
of the fetus. The syphilitic placenta is larger, thicker, and lighter in color 
than normal. Its appearance suggests that it has been soaked in water. 
While the normal placenta is from one-sixth to one-eighth the weight of the 
child, the syphilitic placenta weighs about one-third or one-fourth as much 
as the child. The fact must of course be considered that the syphilitic child 
is less developed; syphilitic fetuses being generally smaller than normal. Macro- 



Fig. 2S4. — Syphilitic Placental 
Villi. Marked proliferation of the 
connective-tissue and round-cell in- 
filtration (5), especially in the neigh- 
borhood of the thickened blood-ves- 
sels (1) ; a few of the villi have lost 
their protoplasmic investment and 
are in process of conversion into 
intervillous thrombi (3); 6, normal 
protoplasm containing nuclei; 7, 
villous blood-vessels — healthy, be- 
longing to the fetus — (original mi- 
croscopic drawing) . — (Schaeffer.) 



248 PATHOLOGICAL PREGNANCY. 

scopically these placentae may differ in appearance. If the fetus has been dead 
some time, the placenta will be very pale in color, soft or slippery, and greasy 
to the touch. If the child lives till term, the organ is commonly unusually 
large and pinkish in color, due to the hypertrophied decidua, which hides the 
true color. Normal villi possess only a few cells but many blood-vessels; the 
syphilitic villi are filled with round cells which have undergone fatty degenera- 
tion and resemble embryonic cells. In syphilitic villi the blood-vessels are 
scarce; the stroma is increased, and is represented by granulation tissue; the 
blood-vessels show endarteritis, and in hardened specimens the villi are seen to 
be thickened. Parts of healthy tissue of the placenta, which intervene between 
the diseased areas, may exhibit extravasations. However, these character- 
istics do not give absolute proof, but probability, of syphilis. Corroboration 
may be furnished from the condition of the child. When gummata are found, 
as in cases in which maternal syphilis antedates conception, they vary in size 
from a hempseed to an olive, and possess the characteristic structure of gum- 
mata in other situations. These formations have a central core of soft yel- 
lowish or reddish cheesy degeneration, surrounded by concentric lamellae, or 
a true abscess cavity, with fatty walls which secrete pus. They often undergo 
fatty and calcareous changes. Diagnosis: It is impossible to make an accurate 
diagnosis during pregnancy. Prognosis: The fetus generally dies rapidly of 
malnutrition, owing to obliteration of the nourishing blood-vessels. Placental 
syphilis is one of the commonest causes of abortion. The greatest maternal 
risk occurs at the time of labor, from adherent placenta and subsequent sepsis. 
The treatment of fetal syphilis will generally be prophylactic. If both parents 
of the future embryo be affected with the disease, then antisyphilitic treat- 
ment should be instituted in both individuals. If only one be syphilitic, it 
would be useless to treat the healthy one. 

7. Secondary Alterations in the Placenta. — Under the head of secondary 
progressive alterations we shall consider hyperplastic and sclerotic changes, 
together "with adherent placenta. Degenerations comprise the results of fetal 
death, white infarction, cystic, fatty and calcareous degeneration, etc. 

(1) Hyperplastic and Sclerotic Changes. — Proliferation of fixed connective- 
tissue cells with an immediate tendency to hyperplasia and an ultimate dis- 
position toward sclerotic and atrophic metamorphosis is a sequel to a number 
of primary placental affections. These changes are due in most cases to 
chronic placentitis, whether the latter be owing to simple endometritis, renal 
disease, or syphilis. Fibrous metamorphosis has received various terms: 
viz., interstitial placentitis; sclerosis of the placenta; scirrhous, tuberculous, 
or cartilaginous degeneration, etc. Much discussion has taken place as to 
the possibility of placental inflammation, hinging on the fact that there are 
no capillaries in the maternal part, and no nerves to regulate the dilatation of 
the capillaries in the fetal tufts. But the process that is productive of an 
excess of connective tissue is exactly analogous to that of cirrhosis of the liver, 
or fibroid phthisis in the lungs; the theory — not the fact — is objectionable. 
Of special clinical interest are the adhesions which form as a result of the organi- 
zation of hyperplastic tissue between the placenta and the uterine wall; and the 
white infarcts, so called, which are due in part to the constriction of certain 
areas of placental tissue by the same sclerotic process. When hyperplastic 
processes terminate in atrophy, they are best considered under regressive 
changes. 

(2) Adhesions. — Adhesions between the placenta and the uterine wall are of 
rare occurrence, for the majority of cases thus characterized are only instances 



ANOMALIES AND DISEASES OF THE PLACENTA. 249 

of simple retention. True adhesion, however, occurs at times, and the two 
structures are then consolidated to such a degree that any natural separation 
is impossible. While authors speak familiarly of the adhesions which result 
from so-called chronic placentitis, those who have especially studied anatomical 
specimens prefer to regard the adhesions as the result of imperfect develop- 
ment (absence of glandular zone, of entire serotina, etc.; see Part II), through 
which the villi become deeply imbedded in the muscular wall of the uterus. 
Nevertheless, cases of undoubted inflammatory adhesion occur, in which in- 
flammatory infiltration has extended from the placenta into the uterine wall 
with resulting organization. There is no danger of hemorrhage from total 
adhesions. If the latter are partial, however, the tendency to post-partum 
hemorrhage is great. (See Part V.) 

(3) Degenerations which Follow Fetal Death. — After death of the fetus 
in utero the circulation persists for a while in the intervillous space, the 
placental tissue remaining intact. The fetal vessels gradually become oblit- 
erated by endothelial proliferation. The stroma becomes changed into fibroid 
tissue. The fixed connective-tissue cells of the pedicles of the villi, chorion, 
and amnion begin to proliferate, with resulting thickening of these structures. 
Langhans's layer and the syncytium also show irregular proliferation. In 
the course of time the syncytium disappears, and the villi become transformed 
into a hyaline substance devoid of nuclei. The circulation in the intervillous 
space ceases as a result of thrombosis. Fatty degeneration, calcification, 
and other degenerative processes are in evidence. The placenta as a whole 
undergoes marked shriveling, becoming small, thin, and of a hardness sug- 
gesting leather or cartilage. Upon section it is white and almost homogeneous. 

(4) White Infarcts. — White infarcts constitute grayish-red, yellowish, or 
pure white areas of the placenta which replace the spongy, highly vascular 
tissue of the latter. At first only moderately firm, they increase in hardness 
progressively from the deposition of lime-salts. In certain cases, however, 
there is a secondary softening of the infarcts, which may terminate in cyst 
formation. Microscopic infarcts occur in all placentae and fully 50 per cent. 
of the latter exhibit infarcts which are visible to the naked eye; hence these 
small formations are physiological. But infarcts of considerable size, also, 
are frequently encountered. The large or pathological infarcts, some of which 
may involve half the placenta, have a various extent and distribution. They 
may be scattered here and there as rounded or stellate areas without any regular 
arrangement, and are then termed insular. Wedge-shaped infarcts have 
their bases in the serotina and their apices among the masses of villi. Annular 
infarcts are sometimes seen, and may involve the free border of the placenta 
or be seated within the periphery. Finally, there is a type of infarcts known 
from its location as the subchorial. The nature and pathology of white infarcts 
have given rise to much discussion. The simplest and most plausible expla- 
nation is as follows: In the hyperplastic and sclerotic changes which have 
just been described, beginning as an endarteritis in the chorionic villi, com- 
pression of placental tissue must necessarily occur at times in certain areas 
which ultimately have their blood-supply cut off and undergo the transforma- 
tion known as coagulation-necrosis. This lifeless tissue becomes changed 
to a homogeneous mass of hyaline appearance, which undergoes various retro- 
grade changes, such as softening, canalization (so-called canalized fibrin), 
cyst formation, calcification, etc. Secondary hemorrhages may occur about 
these infarcts. As these -formations are deprived of blood-vessels, the area 
of the normal placental tissue is diminished to a greater or less extent, so that 



250 



PATHOLOGICAL PREGNANCY. 



m 



the nutrition of the fetus may sutler, even to the extent of abortion. The 
danger to the mother lies in the possibility of the formation of adhesions between 
the infarcts and the uterine wall, with resulting irregular detachment and reten- 
tion of the placenta. 

Williams * has recently examined 500 consecutive placentas for infarcts, 
including both white and red varieties. He found 185 of these specimens 
free from all appearance of such lesions except to an almost microscopic degree. 
But 15 were the seat of the red or hemorrhagic variety. The remaining 300 
placentas all contained white infarcts, distributed as follows: on the surface, 
223, or 44.6 per cent.; purely marginal location, 77, or 15.4 per cent. As 
implied above, microscopic infarcts are invariably present. The mere act 

of infarct formation is physiological, 
and, at best, a normal senile de- 
generation of the placenta. When 
present in a high degree, it is the re- 
sult of some disease, and more espe- 
cially albuminuria, in the mother. 
We are quite unable to explain the 
pathogeny of morbid infarct forma- 
tion, but it seems certain that bac- 
teria play no part therein. The 
inherent independence of albumin- 
uria and eclampsia is shown by the 
fact that we do not necessarily find 
high degrees of infarction in the lat- 
ter disease. 

(5) Cystic Degeneration. — The 
great majority of placental cysts 
result from softening. In some 
cases the latter process is primary 
and results from liquefaction of the 
original myxomatous tissue of the 
placenta. There is some analogy 
between these formations and vesic- 
ular moles. The largest and most 
familiar placental cysts, however, 
result from the softening of infarcts. 
These may attain such dimensions 
as to simulate a second bag of 
waters. This type of cyst is largely 
subchorional in location. The cystic fluid is usually cloudy and contains albu- 
min. Placental cysts may rupture during labor (Fig. 285). 

(6) Calcareous Degeneration. — This is by no means uncommon; as a rule, 
it is not of clinical importance, and lime concretions are sometimes found in 
large numbers. Its occurrence in syphilis has already been mentioned. Pla- 
cental calculi, ossiform concretions, placental ossification, stone placenta, have 
already been noted under the subject of infarcts. These deposits are almost 
always found on the uterine placental surface, in the decidua serotina, whence 
they may extend to the fetal part of the placenta. When the degeneration 
begins in the fetal structures, it is confined to them, and implicates the small 
blood-vessels of the villi, extending from their tiny extremities to their 

* Prof. Welch's Festschrift, 1900. 




Fig. 285. — Multiple Cysts on the Fetal 
Surface of the Placenta. — {Ribemonl- 
Lepage.) 



ANOMALIES AND DISEASES OF THE PLACENTA. 



251 



trunks. These concretions are in the form of grains, needles, or scales. They 
consist of amorphous carbonates and phosphates of lime and magnesia; as 
many as five hundred have been found in one placenta (Chambord). Stony 
scales or laminae or even larger formations may be found in placentae that 
have been left in utero weeks or months after the occurrence of fetal death. 
In the common form, during the life of the fetus, the placental function is not 
disturbed. 

(7) Fatty Degeneration. — This frequently occurs, and modern investigation 
tends to show that fatty change is usually consecutive to the fibrous metamor- 
phosis (Robin-Ercolani). It sometimes occurs in the decidua serotina. Here, 
however, it is part of a chronic endometritis, the placenta being involved 
secondarily (interstitial endometritis of Hegar). A fibrous change may occur 
in the villi themselves, or in the interspaces; the usual contraction, obliteration 
of vessels, and fatty change following. This fatty tissue is friable and greasy to 

the touch. It greases any substance 
with which it comes in contact, and 
is rather firm in consistency. 

(8) Miscellaneous Degenerations. 
— So-called hyaline degeneration is 
a phenomenon which accompanies 




i ft 




Fig. 286. — Separation of the Placenta by a Retro-placental Hemorrhage. The 
figure to the right is the blood-clot removed from the center of the placenta. — (Tarnier.) 



white infarction. Pigment deposits consist of hemoglobin or its derivatives and 
result from extravasations of blood. They are usually small and disseminate, 
and are devoid of pathological significance. Mucous degeneration such as 
attacks the chorionic villi may occur at times in the placenta. 

8. Placental Tumors. — (1) Placentomata: Excluding cysts, which are prob- 
ably better regarded as an expression of degenerative change, and vesicular 
moles and deciduoma malignum which belong to the pathology of the deciduae, 
a number of placental neoplasms — about fifty in round numbers — have been 
placed upon record, all of which appear to be of the same fundamental type. 
The favorite locality is the fetal surface of the placenta near the cord. Much 
more rarely they occur upon the maternal surface or in the substance of the 
organ. They are of a firmer texture than the placenta, from which their out- 
lines and color are well defined, and are also isolated from the placental tissues 
proper by a well-marked capsule. Histologically these tumors are exam- 



252 PATHOLOGICAL PREGNANCY. 

pies of myxoma fibrosum, although some authors prefer the name angioma, 
because of the great number of blood-vessels present. In a few cases of pla- 
cental tumor the structure of sarcoma was approximated. Xone of the re- 
ported cases had any tendency to malignancy. Coagulation-necrosis often 
develops in these tumors. (2) Placental Polypi: These formations are not 
usually included under placental tumors proper, as they represent a disease 
of the uterine cavity which was due originally to the persistence of placental 
residues. They may, however, be described in this connection. Placental 
polypi may be benign or malignant. The formation of the former has been 
described by Pilliet as follows : The fragments that are left behind after abortion 
may either assume new growth, by drawing their nourishment from the uterine 
vessels, or they may have deposited on them blood-clots, which become 
organized and constitute large polypoid tumors. These tumors give origin 
to abundant hemorrhages, muco-sanguinolent leucorrhea which is commonly 
very offensive, together with attacks of uterine colic. The uterus is boggy 
in consistency, large, and subinvoluted. Treatment should include thorough 
uterine curettage. The malignant or destructive placental polyp consists of 
a malignant growth of one villus or of several villi, which are apt to penetrate 
the uterine walls, even as far as the abdominal cavity. Death follows from 
exhaustion, hemorrhage, or peritonitis. 



V. ANOMALIES OF THE UMBILICAL CORD. 

I. Length. 2. Thickness. 3. Insertion. 4. Coils. 5. Knots. 6. Tangling. 7. Torsion. 
8. Stenosis of the Vessels, p. Cysts. 10. Calcareous Deposits. 11. Hernia. 12. Syphilis. 
13. Obstruction of the Vessels. 14. Dilatation of the Umbilical Vein. 75. Hyper- 
trophy of the Valves. 16. Congenital Tumors. 

1. Length. — The cord at term is usually about twenty inches (50 cm.) in 
length; but great variations occur. It is sometimes almost absent, and cases 
have been recorded in which it was four or five feet (122 to 152 cm.) in length. 
There is one case recorded in which the cord attained the length of nine 
feet (2.75 m.); others in which it was only two-fifths of an inch (1 cm.) long 
Deviations from the normal length are sometimes of clinical importance. 
(See Pathological Labor, Part V.) Abnormal shortness may come from natural 
or artificial causes; as, for instance, when adhesive inflammations of the 
amnion result in the gluing together of the coils of the cord, or when the latter 
become attached to the fetal skin or amnion. When it is extremely short, it 
prevents the descent of the fetus, or causes hemorrhage from premature 
placental separation, or even mal-presentation. When very long, it may form 
dangerous coils or knots (Fig. 287). 

2. Thickness. — The cord may develop to the thickness of the adult thumb 
In this case the vessels are normal, there being simply an increase in the density 
of the tissue of the cord (Figs. 296 to 298). 

3. Insertion. — This may be central, lateral (battledore), or velamentous 
(Figs. 255 to 270). In the latter case the vessels of the cord pass between the 
membranes, for a greater or less distance, before reaching the placenta. This 
is due to the fact that during the development of the cord adhesions form 
between the cord and either the amnion or the chorion, thus interfering 
with the formation of the sheath, which normally binds them together. 
The eccentric position is by far the most frequent. Hyrtl's table includes 



ANOMALIES OF THE UMBILICAL CORD. 



253 



many abnormal placentae, and is, therefore, not absolutely correct. It is as 
follows: Eccentric, 54 per cent.; central, 16 per cent.; marginal, 19 per cent.; 
velamentous, 11 per cent. The last percentage is too great, as it is usually 
only 2 or 3 per cent. The velamentous cord is important from a practical 
standpoint, for rupture of the membranes may cause a rupture of the cord 
and the death of the fetus from hemorrhage. This form of insertion is a source 
of considerable danger to the fetus, for the vessels, in their abnormal position, 
are exposed to traumatism, and their rupture may result in serious or even 
fatal hemorrhage, before the delivery of the fetus can be brought about. There 
is an analogous condition in that form called meso-cord, from its resemblance 
to the suspensory structures of the kidney, rectum, or colon. Here the cord, 

instead of having its normal inser- 
tion, is received into an amniotic fold 
which it first traverses. The well- 
being of the fetus is not at all inter- 
fered with by this anomaly. 

4. Coils. — The cord frequently 
becomes wound around the fetus. 
I had a case in my own practice, 





Fig. 287. — Short Umbilical Cord. 



Fig. 288. — Tangling of the Umbilical 
Cords in a Case of Twins Contained 
in One Amniotic Cavity, a, Compli- 
cated knot of both umbilical cords; A, 
the same knot enlarged. — (Ahlfeld.) 



in which the cord was coiled seven 
times around the child's neck, the 
result being the death of the fetus 

(Fig. 296). Another case is recorded, in which it was in nine coils about the 
neck. In 2200 labors I found the cord about the neck in 514 cases, or 23.36 
percent. The cord was coiled once about the neck in 19.77 per cent.; twice 
in 3.18 per cent.; three times in 0.40 per cent. Coiling was called by the 
earlier writers " suicidium foetus in utero" (Figs. 290 to 295). 

5. Knots (Figs. 296 to 298). — These form in consequence of the fetal move- 
ments ; the fetus may pass through a loop in the cord, thus producing a knot ; these 
are of the most varied appearance. They are also due, at times, to uterine 
contractions during labor, before rupture of the membranes, and form a possible 
complication of version. Knots are usually harmless, since the constrictions 
are rarely tight enough completely to obliterate the lumen of the vessels. The 
pulsations of the cord favor the loosening of the knots, on account of the in- 



254 



PATHOLOGICAL PREGNANCY. 



cessant repetition of the shock of pulsation. Rarely a true knot forms ; false 
knots are the result of local increase of Wharton's jelly (Figs. 297 and 298). The 
obstruction of the umbilical vessels causes a more or less complete arrest of the 
circulation, which decidedly hinders the development of the fetus and may 
even cause its death. 

6. Tangling. — In multiple pregnancies the cords sometimes become tan- 
gled, and this accident results nearly always in asphyxiation of both fetuses, 
with their expulsion (Figs. 288 and 289). 

7. Torsion. — This is a twisting of the cord on its long axis. It occurs 
most commonly about the seventh month. It was formerly supposed to 
be due to active movements on the part of the fetus, but it has recently 
been shown that, while a certain amount of torsion may be produced by fetal 
movements, it is never capable of occluding the vessels, and that the higher 




Fig. 289. 



-Coiling of Both Umbilical Cords of Twins, about Each Other and about 
a Leg. Also Two True Knots. — (Winckel.) 



degrees of torsion occur after the death of the fetus (Schauta), and as a result 
of the movements of the mother. Torsion occurs more frequently in the 
case of male children, in multiparas, and with long cords. It usually occurs 
near the umbilicus, and the cord is frequently cedematous and the seat of 
thrombi and cysts. A certain amount of twisting of the arteries around the 
vein is generally seen, commonly ten to twelve twists. 

8. Stenosis of the Vessels. — The umbilical vein is sometimes narrowed by 
a local periphlebitis. This occurs at the placental insertion and usually does 
no harm. Thrombi sometimes form in the umbilical arteries, as the result 
of atheromatous changes, and partially occlude the vessels. If these pro- 
cesses are extensive, corresponding injury to the fetus of course results. This 
stenosis may be congenital. If the involvement concerns only the vein, 
hypertrophy follows, with congestion and oedema of the placenta. If, however, 



ANOMALIES OF THE UMBILICAL CORD. 



255 



the arteries are also affected, the circulation of the fetus will be obstructed 
and the fetus will become cedematous. 

9. Cysts. — Serous and mucous cysts are sometimes found in the cord. This 
may result from cystic degeneration which follows some obstruction to its 
circulation, and as a result a collection of serum formed in the spaces beneath 
the amniotic covering and in the tissues of the allantois. Possibly it is a 






Fig. 290. — Coiling of the 
Umbilical Cord about 
the Fetus and Its 
Extremities. — (McGilli- 
cuddy.) 



Fig. 291. — Coiling about 
a Leg. 



Fig. 292. — Coiling about 
a Leg and an Arm. 






Fig. 293. — Coiling about 
the Neck and Leg. 



Fig. 294. — Four Coils 
about the neck. 



Fig. 295. — Coiling about 
a Shoulder. 



result of the liquefaction of Wharton's jelly, the fluid collecting in the sacs 
that are formed; it may follow apoplexies of the cord. It is not clinically 
important. 

10. Calcareous deposits are sometimes seen, and are supposed to be the 
result of syphilis. They are found in the mucous tissue or in the blood-vessels, 
but are of no importance. 



256 



PATHOLOGICAL PREGNANCY. 



ii. Hernia. — This is the protrusion of some of the abdominal contents at 
the umbilicus, the result of faulty development. The intestines, in the fetus, 
are at first outside the abdominal cavity, and in case of hernia they have either 
failed to enter the abdomen, or, having entered, they are permitted to escape 
through a defect in the abdominal wall. In some cases nearly all the abdominal 
viscera escape. Sometimes the traction exerted by the escaped viscera pro- 
duces deformities of other fetal parts, such as strictures of the rectum, or de- 
formities of the legs. The dilated sheath of the cord envelops the protruded 
viscera. Often the infant is still-born. If the child is born alive, the displaced 
organs must be protected by proper bandages till operation can be performed. 
This affection is really eventration rather than hernia. 

12. Syphilitic Lesions. — Macroscopic lesions are induration of the cord, 
thickening of the vascular coats, disconnection of the funicular vessels, owing 

to the disappearance of mucous tis- 
sue. Histological lesions are endo- 
phlebitis and periphlebitis, endar- 
teritis and periarteritis (Fig. 297). 





Fig. 296. — Coiling of the Umbilical 
Cord Seven Times about the Neck of 
the Fetus. Death of the Fetus and 
Miscarriage. — {Author's case.) 



Fig. 297. — Syphilis of the Umbilical 
Cord. Transverse section showing in- 
flammatory changes of the media and 
adventitia. 1, Vein with thin wall; 2, 
thickened artery; 3, round-cell infiltra- 
tion; 4, stroma of normal myxomatous 
connective tissue; 5, external layer of 
cuboidal cells investing the umbilical 
cord. — (Schaeffer.) 



13. Obstruction of the Vessels. — 

The disconnection of the funicular 
vessels, by the disappearance of mu- 
cous tissue (Wharton's jelly), is a very rare condition; it is known to have 
been due to syphilis, and is accompanied by vascular lesions, such as gumma of 
the external coat of the vein, endophlebitis and periphlebitis. 

14. Dilatation of the Umbilical Vein. — The vein may be the seat of abnormal 
dilatations, of varicosities perhaps as large as a pigeon's egg, and injurious 
to the development of the fetus, on a'ccount of the embarrassment to the cir- 
culation. This condition, however, is generally unimportant, though some- 
times one of the varicose veins will rupture. As a rule, this takes place close 
to the placenta, and a large hematoma is formed. At times the hemorrhage 
is so extensive as to cause fetal death. 

15. Hypertrophy of the Valves. — This also rarely occurs. The etiology is 
probably syphilis; the lumen of the vessel is obstructed, and the situation of 
the valves may be indicated by large nodules. 



ANTENATAL PATHOLOGY. 



257 



16. Congenital Tumors. — Congenital tumors of the umbilicus are of very 
infrequent occurrence. They comprise atheromata and dermoids and so-called 
entero-teratomata. Atheromata and dermoids: In 1892 Pernice was able to 
find reports of but three cases of these tumors in literature.* He describes 

these formations as be- 
nign epithelial tumors. 
Pernice believes that 
dermoids alone originate 
in the scar of the cord 





Fig. 298. — True Knot of the Umbilical Cord. The 
true knot is the center of the three in the left-hand 
figure, the ones above and below are false knots. The 
right-hand figure is the same cord with the knot un- 
tied. — {Author's case.) 



Fig. 299. — False Knot of 
the Umbilical Cord. 



because the latter should 
contain no sebaceous 

glands. Atheromata doubtless originate in the skin around the umbilical scar. 

It is quite likely that the dermoid alone is congenital. Entero-teratomata: These 

growths, also known as adenomata, bear a marked resemblance to ordinary 

granulomata. 



ANTENATAL PATHOLOGY. 

Embryonal and Fetal Pathology in General. — Ballantyne and others make a 

sharp distinction between fetal and embryonal pathology. During the period 
of embryonal life, which is computed by various authors at from six to twelve 
weeks, what is known as organogenesis occurs. In other words, the future 
organs of the body are rapidly differentiated from the primordial embryonal 
tissue, so that at the termination of this cycle they have attained almost com- 
plete development. During the remainder of intrauterine existence there is 
little more than an increase in size, just as in extrauterine life. It seems most 

*"Die Nabelgeschwiilste," Halle a. S. 
17 



258 PATHOLOGICAL PREGNANCY. 

natural to suppose that disease in the embryo must be manifested rather by 
arrested or perverted development of organs than by ordinary pathological 
alterations. A slight malformation of an embryonal organ must increase in 
size with the growth of the latter; in no other way could the occurrence of ex- 
tensive malformations be explained. But there is a close association between 
deformities and diseases; this causes the surmise that certain conditions which 
appear to be diseases of the fetal period have in reality an earlier or embryonal 
origin, and are themselves, therefore, malformations. On the other hand, a 
few true deformities may arise during the fetal period because organogenesis, 
while nearly completed in the earlier weeks of gestation, goes on, to a certain 
extent, throughout intrauterine life, and, indeed, through many years of indi- 
vidual existence. Those structures in which complete development is delayed 
include the bones, teeth, genitals, etc. The pathology of the embryonal period, 
then, is currently believed to be co-equal with the subject of teratology, or mon- 
strosities, including malformations. We are still deeply ignorant as to the manner 
in which such conditions are produced. Studies of very early embryos which 
have perished either from intrinsic causes or from affections of the membranes 
throw hardly any light on the genesis of monstrosities. There can be little 
doubt that abnormal development of the amnion, with or without the forma- 
tion of adhesions and constricting bands, would work havoc with the embryo, 
and probably the fetus as well, but the solution of the problem is hardly 
advanced by this theory. On account of the absence of facts in regard to 
teratogeny, I have omitted this subject, and after a brief account of the little 
that is known of embryonal pathology, shall pass to a description of (i) mon- 
strosities; after which we shall be in a position to take up (2) the diseases of 
the fetal period of intrauterine life, and (3) death of the fetus. 

Pathology of the Early Human Embryo. — Professor Mall, of Johns Hopkins 
University,* has examined over fifty pathological embryos at very early 
stages of development. He states that after the second week pathological con- 
ditions are readily recognizable. Diseases of the very young ovum are of two 
kinds: primarily embryonal and primarily chorial. In the first group the 
embryo is affected while the development of the chorion is unchanged. In the 
second group the chorionic disease results in the strangulation of the embryo. 
Roughly speaking, these affections may be represented pathologically as con- 
sisting in three degrees: viz., (1) simple arrest of development, (2) partial 
destruction of embryo, (3) total destruction of the same. About twenty-three 
cases studied by Mall were examples of arrested development, while in five 
the embryo was partly, and in eight completely, destroyed. Eight cases were 
also noted in which the disease appeared to originate in the umbilical vesicle. 
It would appear that in the majority of cases the pathological process began 
in the embryo. The chorion is endowed with great vitality and is able to 
exist independently and undergo normal development for a considerable time 
after the death of the embryo, but finally its independent existence comes to a 
standstill, and it either persists as a cystic formation or collapses to form a 
fleshy mole. On the other hand, the embryo undergoes rapid destruction if 
the chorion becomes affected. In computing the period at which abortions 
occur we must naturally be guided by the degree of development of the chorion, 
not by that of the embryo. In simple arrest of development we may note the 
coincidence, for example, of a two weeks' embryo in a four weeks' ovum. 
* Professor Welch's Festschrift, 1900. 



VI. DEFORMITIES AND MONSTROSITIES OF THE FETUS. 

CLASSIFICATION. 



i. Heterotaxy. Splanchnic Inversion. 



2. Hermaphro- 
dism. 



f Complete. 
\ Incomplete. 



Anomalous 
Individuals. 



Hemiterata. (Anomalies of : 



Androgynoides. 
f(i) Growth. 

(2) Non-union. 

'(3) Cleavage. 

(4) Structure. 

(5) Persistence. 



Gynandroides. 

f (a) Excess. 
1 Defect. 



b) 



(A) SINGLE 
MONSTERS 

(Including 
incidental 
M onsters 
or Anomal- 
ous Indi- 
viduals). 



(Subdivided accord- 
\ ing to locality. 

f (a) Redundancy. 
\ (b) Defect. 

Microscopic. 

J Non-disappearance 
1 of fetal structures 



Essential 
Monstrosi= 
ties. 



Terato- 

MELUS. 



,2. Teratocor- 

MUS. 



|3. Teratoce- 

PHALUS. 



4. Teratopro- 

SOPUS. 



(1) Ectromelus. 

(2) Symelus. 



V (6) Conforms™. j'tSf <»> 

f (a) Hemimelus. 

\ (b) Phocomelus, etc. 



|(0 

((2) 



Complete. 
Partial. 



volving spine 



((a) Di 
■{ (b) M< 
{(c) Ap 

Celoco 
J (a) Te 
\(b) Te 

((a) Ini 
< (b) Ex 
{(c) An 



pus. 
Monopus. 
Apus. 



Celocormus. 

(a) Teratothorus. 

(b) Teratosoma. 

(a) Iniencephalus. 

Exencephalus. 

lencephalus. 

(a) Hemicephalus. 

(b) Encephalocele. 



f (1) In 

(^ (2) Local. 

(1) Aprosopus. 

, Schistoprosopus. 

(.) Paraprosopus. j^S* "" 8 - 

Synotia. 



Homologous Normal Twins. 



, Separate 
Twins. 



2. Omphalo- 

SITES. 



(B) DOU- 
BLE MON- 
STERS. \ 



AUTOSITES. 



II. United 
Twins. 



Parasites. 



I Paracephalus. 

.Acephalus. 
I Amorphus. 



1. Dicephalus 
(epischistos) 



Dipygus 
(hyposchistos) 



,3. Amphischistos. 



Heterotypus. 



Heteralius. 



1,3. Endocyma. 



% 



1. Anceps. 
Dipus. 
Apus. 
Acormus. 



Thorus, Athorus, Acormus. 



Mylacephalus. 
Anideus. 



(1) Sympygus. 



(2) Monopygus. 



(1) Syncephalus. 



Lecanopagus. 
Ischiopagus. 
Pygopagus. 
Somatopagus. 

fMonolecanus. 
< Monosomus (dipro- 
(. sopus). 

iopagus. 



(Craniopagus 
< Hemipagus. 
(Janiceps. 

4 Mo„ocepha,us. {$ gJSgJSt. 

((a) Sternopagus. 
-< (b) Xiphopagus, 
( etc. 



(1) Thoracopagus. 



(2) Rachipagus. 

(a) Thoracopagus parasiticus. 

(b) Dicephalus parasiticus. 

(c) Acephalus. 

(d) Athorus. 

(e) Apygus. 

(a) Craniopagus parasiticus. 

(b) Ischiopagus parasiticus. 

(c) Dipygus parasiticus or polymelus 
(notomelus, pygomelus, etc.). 

(a) Polygnathus (epignathus, etc.). 

(b) Sacrococcygeal tumors. 

(c) Fetal inclusion. 



(C) TRIPLE 
MONSTERS 



Tricephalus. 



The illustrations of deformities and monstrosities are taken mostly from Ahlfeld's Atlas. 
Hirst and Piersol's Atlas and from photographs and drawings of the author's cases. 

259 



A few are from 



260 PATHOLOGICAL PREGNANCY. 

DESCRIPTION OF MONSTROSITIES, 

(A) SINGLE MONSTERS INCLUDING ANOMALOUS INDIVIDUALS. 

I. INCIDENTAL OR ANOMALOUS INDIVIDUALS. 
I. HETEROTAXY. 

The derivation is from erepoq, "other," and t«££<t, " disposition " — anomalous 
order. Reversal of natural position of organs, as liver on left side or pyloric 
and cardiac ends of stomach reversed. The pathogeny may be explained by 
the asymmetrical development of an organ, one side atrophying while the 
other reaches normal development. If there is interference with the usual 
manner of development, there may result a growth in an abnormal position. 

i. Splanchnic Inversion. — By this congenital anomaly a certain number of 
organs are affected, although their functions are not altered. The relative 
position of the organ, as well as its relation to the adnexa, is disturbed. This 
inversion may be total (Fig. 300) or partial; in the former, all the viscera are 
inverted; in the latter, which is rare, one organ only may be concerned; for 
example, the lung. Anomalies in position of the heart or its great vessels 
also furnish examples. 

2. General Inversion. — The whole organism is concerned, external as well 
as internal organs. This condition necessitates asymmetry and cannot exist 
in an organism in which the two halves are symmetrical. Etiology: In the 
embryo nearly all of the visceral organs are symmetrical; asymmetry, when 
present, may be due to several causes. In an organ which is primarily double 
and situated on both sides of the median line, one part may persist while the 
other disappears. If the persisting portion (normal) should atrophy, inversion 
occurs. 1 If, for example, in the case of the liver, there should be atrophy of 
the right lobe and hypertrophy of the left, hepatic inversion would take place. 
The external form of the organism is preserved in splanchnic inversion, the 
viscera only are affected. General inversion occurs only in the lower animals. 

2. HERMAPHRODISM. 

This condition is a vicious conformation of the sexual organs comprising 
elements of both sexes. When called upon to make the diagnosis, the prac- 
titioner should always exclude an ill-developed male with cleft scrotum or 
rudimentary penis. By this error males have been educated as females. 

1. Complete or True Hermaphrodism. — This condition is very rare. Klebs 
makes the following divisions: (a) Bilateral hermaphroditism — the existence 
on both sides of a testicle and an ovary (Fig. 306 and 307). (b) Unilateral 
hermaphroditism — on one side an ovary and a testicle, on the other side one 
gland only, (c) Lateral hermaphroditism — testicle on one side, ovary on the 
other (Fig. 309). 

Etymological Key. — Prefixes: a- or an-, "absence of"; syn- or sym-, "fusion," or 
"blendingof two symmetrical structures "; mono-, "single," "undivided"; di-, "two"; tri- t 
"three"; anti-, " opposed" or "opposite "; tetra-, " four " ; epi-, " above"; hypo-, "below"; 
ectro-, " abortive," " defective," "rudimentary"; schisto-, "cleft"; micro-, " small "; hemi-, 
"half." Suffixes: -pagus, "united," "connected"; -schistos, "cleft." Parts of Body: 
-cephalus, "head"; -cormus, "trunk"; -pygus, "breech"; -melus, "limb" ("extremity"); 
-thorus, "chest "; -notos, "back"; -prosopos, "face"; -crania, "skull"; -rachis, "spine"; 
-lecanus, "pelvis"; ischio, "seat-bone"; -pus, "foot," "leg"; -brachius, " arm" ; -ophthal- 
mos, -opos, "eye"; -otos, "ear." 



SOME OF THE MONSTROSITIES AND DEFORMITIES 
OF THE FETUS INCLUDING SIMPLE ANOMALIES 
A. SINGLE MONSTERS 

INCIDENTAL 

I.HETEROTAXY 




COMPLETE TRANSPOSITION OF VISCERA 
FIG. 300 



Minovici and Juvara: "Archives des Sciences Medicales," in, i< 

261 



EXTERNAL MALE GENITALS SIMULATING ^E ORGANS ^^^ ^^ GENJTALS SIMLTATLNC MALE ORGANS 
F1G.301 FIG 302 F ir, ana ptp. roa FIG. 305 



2 HERMAPHRODISM 
EXTERNAL 



i^52^ iS 





FIG.303 

INTERNAL 



FIG.304 




COMPLETE (BILATERAL^ 

HERMAPHRODISM 

FIG. 307 



COMPLETE (^LATERAL, UTEB ^, G ^ C s UlJNU3 

■ hew f?o ,H 3 B o°6 D1SM 3. HEMITERATA 



INCOMPLETE (UNILATERAL) 

HERIS LAPHRODTSM 
FIG.309 



( 1 ) ANOMALIES OF GROWTH 




OVERGROWTH OF FEET 
FIG 313 



OVERGROWTH OFLEG 
FIG 314 



K, OVERGROWTH OF ONE HALF OF FACE 
«^^ FIG .315 



DEFECT OF HIP JOINT 
FIG. 3 21 



262 



(2) ANOMALIES OFNON UNION 





PERSISTENT 
HARELTP AND CLEFT PALATE BRANCHIAL CLEFT 

FIG. 323 FIG. 327 



DOUBLE HARELIP 
FIG. 3 24 




SINGLE HARELIP 
FIG. 322 






TRACHEAL FISTULA 
FIG. 326 



BUCCAL FISTULA 

FIG.325 CONGENITAL UMBILICAL HERNIA 

FIG. 328 




SPLIT PEL-MS 
FIG. 329 





EXSTROPHY OF THE BLADDER EPISPADIAS 

FIG.330 FIG. 331 



HYPOSPADIAS 
FIG. 332 




fm 



LUMBAR SPINA 

BIFIDA 

FIG. 335 

CERVICAL SPINA BI FIDA 
FIG.333 



HYDRENCEPHALOCELE 
FIG. 337 




LUMBAR SPINA 
BIFIDA 
FIG.334 



ENCEPHALOCELE 
FIG. 338 



263 



(3 ) ANOMALIES OF CLEAVAGE 




POLYMASTIA 
FIG.344 



double gallbladder 

F1G.345 



SUPERNUMERARY VERTEBRAE (TAIL) 
FIG.348 



(6)VICES OF CONFORMATION 




\-ULVOVAGlNAL ANUS 
FIG. 353 



ATRESIA ANI FT RECTI 
FIG.359 



ATRESIA RECTI 
FI0.3 6O 



ATRESIA ANI 
FIG.358 



264 



ESSENTIAL MONSTERS 

1 . TERATOMELUS or limb monstrosity. 











PHOCOMELDS 
FIG. 361 



51REN0MELUS 
FIG.364 



2 .TERATOCORMUS or trunk monstrosity. 




PLEUROSOMA 
FIG 3 69 



FISSURE OF DIAPHRAGM 
'FIG.370 



CELOSOMA 
FIG. 368 



265 



5.TERATOCEPHALUS or head monstrosity. 




PODENCEPHALUS HYPERENCEPHALU5 

"* FIG. 379 F1CL380 



EXENCEPHALUS 
FIG.378 



4-.TERATOPROSOPUS or face monstrosity. 




SCHISTOPROSOPUS 

IUN11.ATERAIJS, 

FIG. 384 



RHINOCEPHALUS 
FIG. 387 



CEBOCEPHALUS 
FIG. 386 



OTOCEPHALUS 
FIG.392 



3 COBNE/ 

CYCLOCEPHALUS 
FfG.390 



266 



B. DOUBLE MONSTERS 

1. SEPARATE TWINS 

(1. HOMOLOGOUS NORMAL TWINS) 

2-OMPHALOSITES or placental parasites. 




t 




<M 



PARACEPHALUS dipus 
FIG. 3 94 



PAPvACEPHALUS ACORMUS 
FIG. 395 





PARACEPHALUS ANCEPS 
FIG 393 




ACEPHALUS ATHORUS 
FIG. 397 



MM.ACEPHALLTS 
FIG. 398 




ACEPFtALUS THORUS 
FIG. 396 



267 



1 1. UNITED TWINS 
AUTOSITES 

1. EPISCHISTOI (CLOVEN ABOVE) 

rr 

3, 




MONOSOMUS TETROPHTHALMUS 
FIG. 410 



MONOSOMUS TRIOFHTHALMUS 
FJG.409 



MONOSOMUS TRIOTUS 
FIG 411 



268 




2. HYPOSCHISTOI (cloven below 




CRANIOPAGUS FRONTALIS 
FIG.413 



CRANIOPAGUS PARIETALIS 
HG.414 




CRANIOPAGUS OCCIPITALIS 
FIG. 41 5 




MONOCEPHALUS DlBRACHIUS DIPUS **"^ 

FIG 420 

MONOCEPHALUS DlBRACHIUS TETRAPUS MONOCEPHALUS DlBRACHIUS TPJ PUS 
HG.422 FIG. 4 21 



5 . AMPHISCHISTOI (CLOVEN ABOVE and below 




STERNOPAGUS 
FIG. 423 



THORACOPAGUS TRIBRACHIUS 
FIG.425 



PROSOPO THORACOPAGUS 
FIG. 427 



269 



PARASITES. 




CRAN10PA.GUS PARASITICUS' 
FIG- 433 




ISCHIOPAGUS PARASITICUS 
FIG. 432 






DIPYGUS CEPIIALOMELUS JDIPYGUS THORACOMELUS DIPYGUS GASTROMELUS DIPYGUS PYGOMELUS 



FIG. 43 4 



FIG. 43 5 



FIG. 43 6 



FIG. 437 

C TRIPLE MONSTERS 

TRICEPHALUS. 




EPIGNATHUS 
FIG 43 8 



FETAL INCLUSION 
FIG. 441 



SACROCOCCYGEAL TUMQR 
FIG.44Q 



270 



DEFORMITIES AND MONSTROSITIES OF THE FETUS. 271 

2. Incomplete or False Hermaphroditism. — (A) Androgynoides — predomi- 
nance of male type (Figs. 301 and 302). This genus is distinguished by the pres- 
ence of testicles with a considerable degree of development of female genitals. 
In the complete form we find associated the so-called uterus masculinus with 
tubes, and separate excretory ducts for the urethra and uterus. In the incom- 
plete form of the internal variety the prostate is replaced by a uterus mas- 
culinus. In the external variety the external genitals are of the female 
type and the general habit is also feminine. For the above classification, 
taken from Ahlfeld, may be substituted the older arrangement, which, while 
less scientific, is more readily comprehended by the student, (a) Andro- 
gynoides Gynecomastes — breasts simulate . feminine type, while the external 
genital organs resemble those of the male; the fused scrotum with slight median 
depression resembling the vulva surmounted by a slightly developed penis; 
there is absence of testicles in the scrotum, (b) Regular Androgynoides — 
the external genitals of the feminine type are well proportioned; ovaries are 
replaced by testicles which are found in the abdomen or inguinal canal. These 
women (so called) preserve the feminine appearance throughout life, (c) 
Irregular or Hypos padic Androgynoides (Figs. 303, 304, 305) — the feminine type 
prevails in the external genitals, but their constituent parts are ill propor- 
tioned; the vulva is rudimentary while the clitoris-like penis is well developed. 
There is a condition in these individuals of scrotal, or rather perineo-scrotal, 
hypospadias. 

(B) Gynandroides — predominance of the female type (Figs. 303, 304, 305). 
This genus is characterized by the presence of ovaries associated with persistent 
male apparatus. In the complete type we see a general masculine conformation 
of the external genitals and of a portion of the sexual passages. In the incom- 
plete type of the internal variety the vasa deferentia and tubes are both present. 
In the external variety the external genitals approximate the male type. 

Despite the extensive literature of hermaphroditism and the number of 
reported cases, there has never existed an individual possessed of complete 
sets of generative organs of both sexes. Although true hermaphroditism in 
the human being is so rare a condition, it is normally found in many species 
of plants and exists in many worms and mollusks. No instance of the power 
both to impregnate and to become pregnant has ever been known among these 
human individuals. Embryology: There is a certain period in the life of the 
fetus when the male and female elements are equally present; the first prin- 
ciples of both ovary and testicle exist in the sexual eminence, and this may 
develop either into a male or female organ; if female, M tiller's duct develops 
and the Wolffian duct atrophies; in the development of the male the condi- 
tions are just reversed. Hermaphroditism is the consequence of bi-sexual 
growth with equal energy, which may continue till adult life.* 

3. HEMITERATA. 

This term is derived from 9/", "the half," and ~£pas, "monster" — semi- 
monster; i. e., an approach to monstrosity. Under it are included the 
following : 

1. Anomalies of Growth and Development. — (A) Of Excess. — (a) General 

Macrosomia (Giantism): This condition may not be noticed until after birth; 

the bony skeleton and musculature are chiefly concerned and there is often 

suppression of the sexual function, (b) Local: Single parts only may be 

* Prof. Cesare Taruffi (Hermaphrodismus and Zeugungsunf ahigkeit , Berlin, 1903) de- 
scribes a complete bilateral hermaphrodism. 



272 PATHOLOGICAL PREGNANCY. 

enlarged. From the tendency of these local hypertrophies to occupy ex- 
tremities — such as parts of the head, arms, and legs — many of them can 
be grouped under the designation acromegaly. Such malformations are fre- 
quently unilateral. There are other local anomalies of overgrowth connected 
with acromegaly. Many organs may exhibit congenital overgrowth. Some 
of these are the breasts, penis, cornea, eye, etc. There is hardly an organ 
in the body that may not exhibit this anomaly. Entire tissues may also 
exhibit this trait, as in congenital obesity. But certain of these hypertrophies 
are apparent rather than real. Thus, macrocephalus is really hydrocephalus. 
The increase in volume is due to effusion of fluid and the actual tissues exhibit 
atrophy. 

(B) Anomalies of Defect. — With Full Development. — (a) General 
Dwarfism (Nanosomia, Microsomia): Dwarfs are less than 3 feet 9 inches 
(112 cm.) tall. In some of them the body is well proportioned, while in others 
the head and trunk are relatively unequal, (b) Local: Organs and portions of 
the body may exhibit diminutiveness in size with full development. Thus the 
disease known as chlorosis appears to be associated with hypoplasia of the 
aorta. It is doubtless true that any organ or tissue may exhibit this tendency, 
although examples are not so numerous or striking as in the case of local over- 
growth. 

With Arrested Development. — These anomalies are necessarily local, but in 
some of the omphalositic monsters we may find a universal abortive state of 
all the organs and tissues. Nearly every organ in the body may be congenitally 
absent or represented only by an abortive or rudimentary structure. Some 
of these lesions are doubtless due to fetal disease or trauma. Microcephalia, 
perhaps the most familiar member of this category, is held to be due to pre- 
mature ossification. Rudimentary genital organs are common in herma- 
phrodism, and also aside from this anomaly. The same tendency is seen 
in the structures involved in the secondary sexual characteristics, as the beard. 
(Compare Figs. 310 to 321.) 

2. Anomalies of Non-union. — (A) Of the Face and Neck. — (a) Hare- 
lip. — This condition is a congenital fissure or perpendicular division of 
one or both lips. Simple: may be unilateral (Fig. 323) (generally the left) 
or bilateral (Fig. 324); complicated: large fissures resulting in the communi- 
cation of the nasal fossae with the mouth cavity, in which not only the upper 
lip but also the alveolar border, and sometimes the velum of the palate, may 
be concerned (Fig. 323). Pathogeny: There are three buds or centers which 
form the embryonal origin of the upper lip, the two maxillary normally 
unite and fuse in the median line. According as arrest of development takes 
place in one or both of the maxillary centers will the resulting hare-lip be uni- 
lateral or bilateral. If these two centers have been synchronously arrested 
in their development in their whole extent, the deformity will be complicated 
by division of the palatine arch. Nursing is rendered very difficult, if not 
impossible; the infant must be fed by the spoon. In the case of simple hare- 
lip operation should be advised soon after birth, performed with the least 
possible loss of blood. But if the case is complicated, a delay of from two 
to four years is expedient, since the operation will entail a considerable loss 
of blood. 

(b) Congenital Fissures of the Palatine Arch (Fig. 323). — The congenital 
palatine division may be total or partial, frequently complicating hare-lip, 
though it may exist by itself. When there is absence of the partition, it is 
median; when the vomer persists, it is bilateral; or if the vomer be inserted 



DEFORMITIES AND MONSTROSITIES OF THE FETUS. 273 

on the border of the division, it is lateral. Nursing may be impossible. It 
is preferable to wait until the child is between eight and eleven years old before 
attempting an operation. At the present day a false palate is believed by 
many to give better results than a so-called surgical palate. 

(c) T r ache o-e so phage al Fissure (Fig. 326). — This is a very rare condition. 
Every attempt at swallowing causes strangling and cough and the milk is 
expelled. Death supervenes soon, either from starvation or traumatic pneu- 
monia. Gastrostomy is the only treatment for this condition. Numerous 
other congenital fissures, fistulas, and cysts occur in the region of the head 
and neck, such as buccal fissure (Fig. 325), which enlarges the mouth (macro- 
stoma) ; tracheal fistula ; branchial fistula (imoerf ect closure of the fetal bran- 
chiae), etc. (Fig. 327). 

(B) Of the Trunk. — Many of these results of non-union are so grave that 
they can be considered only under the head of major deformity or monstrosity. 
The best example of minor deformity is congenital umbilical hernia. 

(a) Congenital Umbilical Hernia (Fig. 328). — This malformation consists of 
a tumor at the umbilicus, which is formed by the protrusion of one or more 
of the abdominal viscera. It is due to an embryonal defect of the muscular 
layers, which fail to cover their normal area, and not to the distention of the 
abdominal wall, (a) Embryonic: This form constitutes more of an eventration 
than a hernia, as sometimes a large part of the liver or the heart or a great 
mass of intestines may be implicated. (See Part IX.) (£) Fetal: At the third 
month the child is so far developed that only a comparatively small opening 
forming a ring can be formed at the umbilicus. In extreme cases of the em- 
bryonic variety operation has been performed at once with successful results. 
However, in the less marked instances some mechanical contrivance is generally 
sufficient, as, for example, a simple folding of the skin itself, held in place over 
the umbilical region by means of adhesive plaster; or a covered wooden button 
is pressed into the ring and held firmly by plaster strips. 

(C) Of the Pelvis and Genitals. — (a) Exstrophy of the Bladder or 
Extroversion (Fig. 330). — The essential characteristic of this condition is the 
absence of the anterior part of the bladder. The posterior wall of the viscus 
is so fused with the linea alba that it appears to constitute part of the abdominal 
wall. This malformation does not, as a rule, occur by itself, being often accom- 
panied by epispadias in particular. It is very distressing, as there is a constant 
escape of urine. The orifices of the ureters are plainly visible. Operation 
should be delayed until the third or fourth year, and then the best treatment 
will consist in making for the bladder a cutaneous covering so that a urinal 
may be applied with some convenience. 

(6) Hypospadias (Fig. 332). — Hypospadias is a malformation in which the 
meatus or urethral opening is situated not at the apex of the glans, but on 
the under side of the penis at a greater or less distance from the symphysis. 
Frequency: 1 : 300 (Bouisson). The etiology is due to a defect in the embryonic 
development of the urethra. There is usually an accompanying atrophy of the 
corpora cavernosa and a marked curving of the penis. Varieties: (a) Balanic — 
opening on the inferior surface of the glans. (/?) Penile — opening on the inferior 
surface of the penis, (y) Peno-scrotal ; — opening at the junction of the penis 
and scrotum, (d) Perineo-scrotal — opening at the junction of the perineum and 
scrotum. Treatment: The fibrous band which causes the curving of the penis 
should be cut and the canal reconstructed by means of successive plastic 
operations. 

(c) Epispadias (Fig. 331). — Epispadias is that malformation in which the 
18 



274 PATHOLOGICAL PREGNANCY. 

urethral opening is placed on the dorsum of the penis. It is far rarer than 
hypospadias. Varieties: (a) Balanic — opening at the base of the glans. 
(/?) Penile — opening on the dorsum of the penis. (y) Complete — opening at 
the level of the pubis. The last-named variety is the most frequent. As in 
hypospadias, the canal should be gradually reconstructed. 

(d) Uterus Septus and Vagina Septa. — Duplicity of the birth canal exhibits 
numerous degrees, dependent upon the period of arrest of development of 
Muller's ducts. (See Malformations of Genital Organs, Part IX.) 

(D) Of the Cranium and Spine. — Major defects of the cranium belong 
under the head of monstrosities. 

Minor Defects of Formation of the Skull and Spine. — (a) Congenital Hydro- 
cephalus (Figs. 443 an d 444)- — Definition: An excessive accumulation of cere- 
brospinal fluid within the brain (see Antenatal Diseases of the Fetus, page 285) or 
its membranes, causing enlargement of the skull. The serous effusion is generally 
confined to the ventricles, although it may be found in the interstices of 
the pia mater, in the parenchyma of the cerebrum, or between the arachnoid 
and the dura mater. Frequency: This affection is rare, occurring once in 





Figs. 443 and 444. — Hydrocephalus. Two Views of the Same Skull. (3- natural size.) 

— (Author's collection.) 

about 3000 deliveries. Pathology: The skull becomes enlarged, sometimes 
enormously so, by the pressure of the increasing quantity of the fluid; the 
closure of the fontanelles and sutures is delayed, and the edges are separated 
more or less widely; the bones become very thin, sometimes like parchment; 
the skull is much larger proportionately than the face, the forehead being 
especially prominent. The head may even reach the size of that of an adult; 
the body, as a rule, is normally developed, and is of the size which corresponds 
to the period of pregnancy, but is often wrinkled and emaciated. Other mal- 
formations, as meningocele, frequently coexist, and hydramnios is a common 
accompaniment. The quantity of liquid in the ventricles may reach several 
pints. The head is shaped like a wedge, with the base upward; the charac- 
teristic deformity produced by the normal size of the face and lower part of 
the skull, surmounted by the enormously distended upper part, is very 
striking. The eyes are very deeply set, and their axes point obliquely inward, 
so that they look crossed, and the deformity is often hideous, from the promi- 
nence of the eyes and the overhanging forehead (Fig. 443). With this affection 
polyhydramnios is commonly present, but rarely will hydrorrhachis be found. 
There is a decided tendency, on the part of the mother, to rupture of the 



DEFORMITIES AND MONSTROSITIES OF THE FETUS. 275 

uterus. It is not rare to find the head measuring from 13 to 16 inches (33.02 
to 40.64 cm.) (Spiegelberg). Etiology: This is not positively settled. It has 
been observed to occur several times in children of the same mother: in one case 
six (Gohlis); in another seven (Peter Frank). Very rarely have abnormal 
conditions been found in the mother. Frequent anomalies are present in 
the fetus itself and its surrounding parts; namely, spina bifida, club-foot, 
large quantities of liquor amnii, anasarca and ascites, and congenital 
rickets. Most of these defects are due to the same cause as the hydroceph- 
alus. Then, too, may occur diaphragmatic hernia, absence of one kidney, etc. 
(Winckel). Diagnosis: This is not always easy, and the condition is seldom 
recognized during pregnancy. In a small proportion of cases hydramnios 
coexists. Vicious presentations are often present. The large head has sometimes 
been recognized by abdominal palpation, and the art of cephalometry should 
be of service here. Exceptionally certain specially induced phenomena have led 
to the making of a diagnosis, such as the absence of ballottement and parch- 
ment-like crepitation and fluctuation in the fetal head. (See Fetal Dystocia, 
Part V.) 

(b) Meningocele; Encephalocele; Hydrencephalocele. — Meningocele (Fig. 336) 
consists in hernia or tumor in which there is a protrusion of the cerebral mem- 
branes through an opening in the skull. These form a sac, which may or 
may not contain cerebrospinal fluid. In encephalocele (Fig. 338) there is a pro- 
trusion of the brain substance which is connected with the bulk of the brain 
by a constricted neck or pedicle. In this tumor there may or may not be 
fluid. In hydrencephalocele (Fig. 337) there is a protrusion of a portion of the 
brain substance, as in encephalocele, but this contains within its center a cavity 
filled with cerebrospinal fluid and communicating with the distended lateral 
ventricles of the brain. 

Meningocele is rarer than meningo-encephalocele. The occipital and fronto- 
nasal regions form the most frequent seat of these tumors. The size varies 
from that of an olive to an egg-plant. The tumor is always congenital; 
generally it is round and elastic, soft and fluctuating. Its reducibility varies. 
It is always in or near the median line. There is pulsation synchronous with 
that of the heart. Convulsions or even coma may be caused by compression. 
These deformities probably result from an arrest of development of the cranial 
bones. They may be due to arrested or defective development, or they may 
result from an intracranial inflammation, terminating in bands of adhe- 
sion, or to a thinning of the bones of the skull from internal hydrocephalus. 
The head itself may be normal or hydrocephalic. Coincident with these tumors 
is a softening of the cranial bones, which renders expression of the head easier 
in labor. They do not often offer an obstruction to delivery, for, on account 
of their position, they are expelled either before or after the head itself. The 
maximum degree of obstruction will obtain when the tumor is of large 
size, with short pedicle and a lateral position. Prognosis for both mother 
and child is much better than in cases of congenital hydrocephalus. All diffi- 
culty in the expulsion of the fetus is, as a rule, obviated by puncture of the sac. 
After birth the tumor should be carefully guarded from any friction or injury 
(See Fetal Dystocia, Part V.) 

(c) Spina Bifida (Figs, ^t,^, 334, 335). — This is a defect in the vertebral 
canal, which consists of a fluid tumor formed by the protrusion of some part of 
the contents of the canal. It is found at any point of the spinal column, but most 
frequently at the cervical or near the end of the dorsal region. Among the con- 
genital deformities it is one of the most frequent. Spina bifida is thought to be 



276 PATHOLOGICAL PREGNANCY. 

due to early arrested development, taking place generally before the segmentation 
of the cord. Since the dorsal vertebral arches fuse more rapidly than the 
cervical or lumbar, there is more opportunity for the defect to occur in the 
two latter regions. There are two degrees of this malformation: («) Hydror- 
rhachis externa — in which the liquid is between the cord and its envelopes or 
in the midst of the cord in the ependymal cavity; (£) Hydrorrhachis interna 
constitutes a meningocele. In hydrorrhachis interna the tumor contains not only 
the cord but also the spinal nerves arising from it. The tumor is, as a rule, 
associated with spina bifida, though this is not always the case. It may be sessile 
or pedunculated, depending upon the extent of the fissure. The latter may 
be in the vertebral bodies or the tumor may protrude through the intervertebral 
notch or foramen, and point anteriorly — spina bifida occulta. Although the 
tumor is most often single, it may be multiple or it may exist in two 
regions of the canal at the same time. It may be formed before the closure 
of the central canal, or even later, the accumulated fluid causing it to open 
again. Its size varies considerably, though it is often about the size of a nut. 
Any effort at crying or standing distends the tumor. Prognosis: Early death is 
frequent, although the victims of this infirmity have been known to reach 
fifty years of age. The prognosis is greatly influenced by the anatomical 
variety and by the complications. The simple meningocele when covered by 
skin is the most favorable form. Indeed, complete recovery may be hoped 
for. In some cases hydrocephalus has been known to develop after cure of 
the original deformity has been obtained by operation. The diagnosis is 
not difficult as to recognition of the general condition. It is not so easy to 
distinguish the different varieties. Treatment: If the malformation is not 
extreme, the treatment should be expectant. Inflammation often follows 
injections into the sac or excision of the sac. The tumor should always be 
protected from pressure, and if it is not covered by integument the surface 
must be kept aseptic. For details of the operation a work on operative surgery 
should be consulted. 

3. Anomalies of Cleavage. — These minor monstrosities, which are responsible 
for redundant or supernumerary organs, as well as for the more infrequent con- 
solidations or fusions of naturally double or multiple structures, require no 
extensive consideration in this connection. They are not especially dangerous 
to life, and when they do occur the indications for treatment are very obvious. 
Some of these anomalies are merely pathological curiosities discovered at au- 
topsy; others have a cosmetic significance only; and, generally speaking, the 
entire subject of anomalies of cleavage is devoid of practical bearing (Figs. 343 
to 351). 

4. Vices of Conformation. — (a) Intrinsic. — Here belongs an especial class 
of malformations: viz., imperforation or stenosis of tubular organs. Complete 
obliteration of the esophagus is very rare; when this condition exists, there is 
rejection of milk after it is swallowed; suffocation often occurs on account of the 
milk passing into the larynx. The child lives only a few days, dying of inanition, 
unless gastrostomy is performed. Other important imp erf or at ions are those 
which concern the urethra and rectum or anus. Narrowness of the urinary meatus 
causes slow micturition, and even spasmodic phenomena, with the attendants 
retention and incontinence of urine, which may result. The abnormalities due 
to this condition may cause dystocia. Congenital stricture of the rectum (Fig. 
360) results when there is incomplete absorption of the transverse partition 
formed by the union of the rectal and anal ampullae. Imp erf orations in the ano- 
rectal tract result either from the non-union of the two ampullae or from non- 



DEFORMITIES AND MONSTROSITIES OF THE FETUS. 277 

absorption of the partition after they are united. Congenital stricture may not 
be recognized as long as liquid food is taken; the ingestion of solid food, however, 
is followed by marked phenomena of occlusion. The physician should in every 
case examine the newly born infant for external imperf oration, which may be 
seen without difficulty when it is present (Figs. 358, 359, 360). The discovery of 
internal imperforation will be made only by the observation of its results. The 
infant becomes distressed, makes futile efforts to evacuate the bowels, the abdo- 
men becomes distended, and the skin becomes cadaveric. Exhaustion and death 
occur in a short time. As soon as it is noticed that the infant has no stools 
examination of the rectum should be made either with the little ringer or a sound. 
Treatment: In stricture the rectum should be dilated by one of the approved 
methods; the finger is to be preferred. Imperforations should be remedied 
at once. The difficulty of the operation will increase with the height of 
the rectal ampulla. The incision should be carefully advanced toward the 
sacrum and should never be deeper than four or five centimeters. If the 
ampulla is seen, the most prominent part should be incised, and after the 
meconium has escaped the flaps are sutured to the skin externally. The number 
of intrinsic vices of conformation is very large, since every organ is found to 
exhibit peculiarities in shape. Thus, myopia and hypermetropia depend largely 
upon lengthening or shortening of the antero-posterior axis of the eyeball. The 
subject of pelvic deformity is considered elsewhere (Part V). A well-marked 
type of intrinsic vice of conformation is seen in the varieties of congenital club- 
foot. 

Club-foot. — This defect is a permanent one, and is characterized by in- 
ability to place the plantar surface of the foot on the ground in standing or 
walking. Varieties: Simple (rare). Club-foot — pes varus (plantar surface look- 
ing inward) ; club-foot — pes valgus (plantar surface looking outward) ; club-foot 
— pes talus (the toes pointing up); club-foot — pes equinus (the toes pointing 
down). Combined varieties are frequent. The varus equinus are far more 
frequent than the varus talus. Pathogeny: (1) Mechanical theory. Due to 
uterine compression of the fetus. (2) Theory of muscular retraction. Due 
to some alteration of the central nervous system. (3) Primitive malformation. 
This seems to be the most logical theory. In the varus variety there would 
be inflection of the astragalus. The fetal feet are really in varus position till 
the third or fourth month of intrauterine life. This condition may not only 
continue, but it may increase on account of pressure, adhesions, or an un- 
usually small quantity of amniotic fluid. Diagnosis: Care should be taken 
not to confuse the natural inclination of the foot inward for club-foot. Treat- 
ment: Operation should be performed before the child begins to walk. The 
tendo Achillis is cut and sometimes the plantar fascia. The foot is put up in 
correct position in plaster. After a few weeks this is removed and an orthopedic 
apparatus substituted. After the sixth or seventh month the skeleton of the 
foot cannot be straightened and section of the tarsus must be made. 

(b) Extrinsic. — In this type two or more distinct organs combine to form an 
anomaly of connection or relation. In the large class of abnormal terminations or 
insertions the most conspicuous examples concern the rectum, which may termi- 
nate in and discharge its contents into the urethra, vagina, bladder, perineum, 
preputial sac, etc. (Figs. 354 and 360). This class of anomalies is due to a defec- 
tive formation of the septum between the internal and external cloacae. Some 
of these defects are not a menace to life, and operation may be deferred till the 
child is several years of age. If intervention is necessary for any reason, an 
artificial (iliac) anus should be formed. Another class of deformities to be con- 



278 PATHOLOGICAL PREGNANCY. 

sidered in this connection includes congenital dislocations, that of the hip being 
the chief example (Fig. 321). 

Congenital Dislocations of the Hip (Fig. 321). — This malformation is not gen- 
erally noticed till the child commences to walk. It walks like a duck if the de- 
formity be double. This dislocation is always backward and occurs in movements 
of flexion, of adduction, and of rotation inward This posture which the child 
assumes within the uterus may be due to a poverty of amniotic fluid or to pres- 
sure of the uterine walls. This dislocation may be either unilateral or double. 
In the first form there will be lameness, but the movements of the leg are almost 
completely preserved. In the latter the buttocks are very prominent and the 
gait is distorted. Treatment: Continuous extension should be practised during 
several months. 

5. Vices in the Minute Structure of Organs and Tissues. — Most of these refer 
to errors in ossification, and to anomalies of pigmentation, as albinism. 

6. Anomalies Due to Persistence of Fetal Structures. — The most familiar of 
these are persistent foramen ovale, ductus Botalli, Meckel's diverticulum, 
urachus, thymus, retention of one or both testicles in the abdominal cavity, and 
persistent cloaca (Fig. 356). Congenital inguinal hernia and congenital hydo- 
cele may be regarded as effects of the persistence of fetal canals. 

Ectopia of the Testicles. — Ectopia of the testicle exists when this gland is 
arrested on its way from the abdomen to the scrotum before reaching its normal 
destination. Varieties. — According to number: Unilateral — monorchia, 1: 1000. 
Bilateral — cryptorchia or anorchia, 1: 10,000. According to position: Inguinal 
ectopia (most frequent, it often accompanies hernia). Abdominal ectopia. 
Cruro-scrotal ectopia. Perineal ectopia. 

Congenital Hydrocele. — This consists of an accumulation of serous fluid 
in the tunica vaginalis, and is due to failure of closure of the containing cavity. 
The liquid is clear and transparent and may pass back to the peritoneum. Treat- 
ment: The tumor may be evacuated by a fine trocar if great distention demands 
it, but since it often disappears spontaneously and there is danger, or at least 
possibility, of peritonitis following the operation, it should not be undertaken 
unless necessary. 



II. ESSENTIAL MONSTERS; MAJOR MONSTROSITIES. 
1. TERATOMELUS, OR LIMB MONSTROSITY. 

These deformities when of high degree are placed under the major monstrosi- 
ties because the patient is rendered helpless thereby. In symelus the asso- 
ciated deformity of the pelvis renders survival hardly possible. 

1. Ectromelus, or abortive limb. Complete type: The entire limb may be 
simultaneously involved, as when it is wholely missing (amelus, absent limb, 
Fig. 365); or when uniformly diminutive (micromelus, miniature limb). 
Partial type: Local defects may occur either at the periphery (hemimelus, half 
limb, Fig. 362) or in the continuity of the limb (phocomelus, seal limb, Fig. 
361). In true phocomelus the long bones are all absent, the hands and feet 
being joined directly to the shoulders and hips respectively. It is a mistake to 
apply the term phocomelus to mere shortening of the humerus. Embryologi- 
cally speaking, hemimelus results when the lower segments of the extremity do 
not develop, and phocomelus is brought about by the non-development of the 
upper segments. When ectromelus affects the upper extremity alone, the suffix 
brachius is substituted for melus; thus, abrachius, microbrachius , hemibrachius . 



DEFORMITIES AND MONSTROSITIES OF THE FETUS. 279 

The corresponding terms for the lower extremity are apus, micropus, hemipus, 
etc. If it be desired to express the plural, we use the expressions amelia, 
microbrachia, apia, etc. Some authorities use the terms peromelus, pero- 
brachius, peropus, for a mere stump of a limb, although the designations 
amelus, etc., should include this variety. 

2. Symelus, or fused limbs (Fig. 363). The members of this rare class of 
deformities represent merely three degrees of fusion. Instead of the old nomen- 
clature, symelus, uromelus (tail limb), and sirenomelus (siren-foot), it should 
answer better to classify the deformity as follows : Symelus dipus, in which the 
fused feet are still distinct; symelus monopus (uromelus), when the fusion is 
more extensive, so that but one foot exists; and symelus apus (sirenomelus, Fig. 
364), in which all semblance of a foot has disappeared. Symelus of the upper 
extremity is seen in some cases of dicephalic double monsters. In case of 
possible confusion we may use the terms symbrachius (fused arms) and sympus 
(fused feet, lower extremities). 



2. Teratocormus, or Trunk monstrosity. 

These deformities consist of major anomalies of non-union of the anterior 
or lateral walls of the trunk, with resulting eventration. Collateral malforma- 
tions of the extremities may coexist. The individual forms of these anomalies 
differ in the locality and degree of the defect. Teratocormus may be general or 
partial. 

1. The general malformation may be of two kinds: external and internal. 
The general internal deformity consists of a defect in the anterior wall of the 
entire trunk with prolapse of the viscera of the thorax and abdomen. This con- 
dition may be known as (a) celocormus or celosoma (trunk or body hernia, Fig. 
371). The general internal deformity consists in a defect of (b) the diaphragm 
with resulting displacement of the viscera. 

2. Partial teratocormus may be superior or inferior. The superior type, 
which may be termed (1) teratothorus , or thorax monstrosity, may exhibit 
several degrees: viz., Simple fissure, (a) schisto-thorus , cleft thorax (Fig. 366); 
more extensive defect with hernia of the heart or lungs, (b) celothorus, thorax 
hernia (Fig. 367); and, finally, the type described by Saint-Hilaire under the 
name " pleurosoma " (Fig. 369), in which, in addition to a lateral defect in the 
chest-wall, there is arrested development of the corresponding arm. Inferior 
teratocormus, which may be termed (2) teratosoma, also exhibits several varieties: 
viz., (a) Simple fissure, schistosoma, or cleft abdomen; (6) more extensive defect 
with hernia of the viscera (celosoma, or abdominal hernia, Fig. 368); (c) the 
11 cyllosoma" (Fig. 371) of Saint-Hilaire, in which, in addition to the defect in the 
abdominal wall, there is arrested development of the corresponding lower ex- 
tremity; the (d) " agenosorna" of the same author, in which the defect is asso- 
ciated with arrested development of the genitals; and, finally, the " aspalosoma" 
of the same author, in which the defect is associated with dissociation of the 
urinary and genital apparatus. 

3. TERATOCEPHALUS, or Brain Monstrosity. 

This class of monstrosities really affects the cerebrospinal bony axis, the 
malformation of the brain being largely secondary in character. As in the pre- 
ceding category, the condition is a major anomaly of non-union with prolapse 
of the contained viscera. Teratocephalus may be general or partial. 



280 PATHOLOGICAL PREGNANCY. 

i. In the general or complete type the defect is present both in the cranial bones 
and in the spine. There are several degrees of malformation. The mildest is the 
(a) "iniencephalus" (Fig. 373) of Saint- Hilaire, which is simply a notocephalus or 
occipital fissue of the cranium extending into the spine, with a certain amount of 
hernia of the encephalon. A much higher degree is (b) exencephalus (protrusion 
of the encephalon, Fig. 378), in which the defect is so extensive that the entire 
brain escapes from the cranium and rests upon the back. In the very highest 
degree the cranial vault and brain are both absent, (c) anencephalus, absence of 
encephalon (Figs. 374, 375), or acrania, absence of cranium. This is doubtless 
the most common of all the single monsters. 

2. Partial teratocephalus is localized in the cranium alone. The corre- 
sponding partial defect of the spine known as spina bifida is best considered 
among the minor monstrosities or hemiterata. Some of the milder degrees of 
teratocephalus are also compatible with life and have been mentioned in con- 
nection with the hemiterata under the term hydrocephalus (see page 274). 
Teratocephalus confined to the cranium may be subdivided into two species, in 
accordance with the degree of malformation. If the condition is one of simple 
defect somewhere in the cranial wall, with more or less hernia of the encephalon, 
we may use the term encephalocele * to describe it. On the other hand, if the 
defect is extensive, with arrested development of the brain, the condition should 
be known as hemicephalus (half head) or pseiidencephalns (spurious head) (Fig. 
377). Encephalocele is subdivided into anterior or frontal (a) (proencephalus, 
Fig. 381); superior or parietal (6) (podencephalus, Fig. 379), and a special form 
of the latter known as hyperencephalus (Fig. 380), in which most of the brain has 
prolapsed through the atrophied cranial vault; and posterior or occipital, (c) 
notencephahis (Fig. 376). 



4. TERATOPROSOPUS (FACE MONSTROSITY). 

This major monstrosity may be general or partial. The former, (1) apro- 
sopus (absence of face), comprises certain instances of total or relative absence 
of all the features, which Saint-Hilaire classified under a variety of terms, such 
as triocephalus, stomocephalus, edocephalus, etc. This author attempted to 
place these monsters either under cyclopia or otocephalus. Partial terato- 
prosopus, which may be termed (2) paraprosopus, presents two well-marked 
forms. In the one we have a simple anomaly of non-union, such as has been 
described in connection with the trunk and cranium, which may be termed (A) 
schistoprosopus, or cleft face (Figs. 382, 383). The other monstrosity consists of 
defective development of the facial bones, and may be termed (B) ectroprosopus, 
or abortive face. (A) Schistoprosopus (Figs. 382, 383, 384) may be complete 
or partial. In the first instance the monstrosity consists of complete non- 
union of all the branchial clefts. In the latter an oblique fissure may be present 
either on one side or on both sides of the face. (B) Ectroprosopus maybe 
superior or inferior, (a) The former subdivision is the well-known condition 
cyclopia or synopsia (fused eyes, Figs. 388, 389, 390), due to defective develop- 
ment of the bony apparatus between the orbits, and therefore involving the olfac- 
tory apparatus, (b) Ectroprosopus inferior is the condition known as otocephalus, 
synotia (fused ears), and agnathia (absence of jaws), terms which partly explain 
its nature, (a) Cyclopia, which might also be termed ectrorrhinia, because of 
the abortive development of the nose, is of two principal degrees. In the first 

* Encephalocele when of slight degree may be understood as a mere malformation, 
like spina bifida. 



DEFORMITIES AND MONSTROSITIES OF THE FETUS. 281 

(a) the two orbital cavities are retained, while in the second (6) but a single orbital 
cavity is present. (a) The double-orbit type comprises two varieties; in the 
mildest degree a nose is still present between the eyes, which are close together. 
This degree corresponds to the (a) ethmocephalus of Saint-Hilaire. In the next 
higher degree the eyes are more closely approximated, and between them there 
is a mere rudiment of a nose. This degree corresponds to the (/5) cebocephalus 
of Saint-Hilaire. (/5) In the single-orbit type there may be two eyes, one eye, or 
no eye. In the two-eyed type a rudimentary proboscis is placed above the 
single orbit; this is the (a) rhinocephalus of St. Hilaire (Fig. 387). In the single- 
eyed type (/5) {cy otocephalus of St. Hilaire, Fig. 389), there may be a double 
cornea, a single cornea, or no cornea at all. Finally, in the very highest type of 
cyclopia there is no eyeball present, (y) anophthalmus, absence of eye (Fig. 391). 

(b) In ectroprosopus inferior, or synotia, there is a defect or absence of the 
maxillary bones, with resulting approximation of the ears beneath the face. 
The various degrees present in cyclopia are not encountered in this deformity 
which is also one of great infrequency of occurrence. Simple synotia corre- 
sponds to the sphenocephalus of Saint-Hilaire; the other varieties of synotia, as 
stated by the latter, are associated with malformation or defect of all the features 
and are best considered under aprosopus. They include edocephalus, opoceph- 
alus, and triocephalus. 

(B) DOUBLE MONSTERS. 

TarufB subdivides all double monsters into (I) separate twins and (II) united 
twins. 

I. SEPARATE TWINS. 

These comprise only homologous normal twins and omphalosites. 

1. HOMOLOGOUS NORMAL TWINS. 

These are only technically a double monster. They may originate from the 
complete cleavage of a single ovum, and correspond exactly in their anatomical 
structure. They are described under twin pregnancy. 

2. Omphalosites (Nourished from the Umbilical Cord). 

Of twins which form from a single ovum, one may be properly developed, 
while the other, owing to peculiarities of vascular anastomosis, in unioval twins, 
fails to undergo normal development. One heart predominates over the other, 
which undergoes atrophy. The abortive twin is therefore an intrauterine para- 
site nourished through the blood-vessels of its fellow (whose heart undergoes 
some compensatory hypertrophy) and incapable of extrauterine life. These 
monsters are often termed acardiaci because of the reputed absence of the heart ; 
this organ, however, is often found in a rudimentary state. Omphalosites ex- 
hibit the highest possible type of monstrosity. They are divisible into three 
kinds: viz., paracephalus (imperfect head), acephalus (head absent), and amor- 
phus (void of form). 

1. Paracephalus represents the highest degree of development, and com- 
prises four varieties: (a) P. anceps (Fig. 393) has four limbs, which exhibit 
varying degrees of abortive development. (b) P. dipus (Fig. 394) has lower 
extremities only, (c) P. apus has no limbs, (d) P. acormus (Fig. 395) has 
neither limbs nor trunk. 



282 PATHOLOGICAL PREGNANCY. 

2. Acephalus has no head, but may exhibit considerable development of the 
lower extremity of the body. In the variety (a), A. thorus (Fig. 397), the 
trunk is developed (Fig. 397). In (b), A. athorus (thorax absent), the superior 
extremity of the trunk is undeveloped (Fig. 396). In (c), A. acormus (trunk 
absent), or pseudocormus, the entire trunk is undeveloped or in an abortive state, 
the monsters consisting chiefly of lower extremities. 

3. In the amorphus the degree of development is very slight, the monster 
consisting only of a rudimentary trunk, (a) Amorphus mylacephalus has rudi- 
ments of limbs (Fig. 398), but in Amorphus anideus there is no resemblance to a 
human organism (Fig. 399). 

II. UNITED TWINS. 

United double monsters are divided, like the separate double monsters, into 
symmetrical and asymmetrical. The former are double autositic monsters ; i. e., 
each is capable of independent existence, while the latter consists of an autosite 
and a parasite. While the former are simply homologous twins united by some 
portion of their bodies, invariably the same in each of the two individuals, the 
latter resemble the combination of normal twin and omphalosite, with this differ- 
ence — that the parasite is directly united to its fellow. 

AUTOSITES ; SYMMETRICAL DOUBLE MONSTERS. 

These monsters are readily subdivided into three families, as follows: (1) 
The twins may be separate above and fused or single below, and may be termed 
epischistoi (separate above) or dicephali (two heads). They have also been 
known by the designation katadidyma. (2) The twins may be separate below 
and fused or single above, and may be termed hyposchistoi (separate below) or 
dipygi (double breech). The old term for these monsters is anadidyma. (3) 
The twins are separated both above and below, having both heads and breeches 
distinct, and are united at the region of the waist. This family may be termed 
amphischistoi (both separate). The old term to describe this form of monstrosity 
is anakatadidyma. 

1. Epischistoi or Dicephali. — The dicephali are divided into two genera: viz., 
sympygus, or fused breech, and monopygus, or single breech. (1) In Sympygus 
the twins may be united by the pelvis alone, (a) lecanopagus, or by the entire 
trunk, (b) somatopagus. The (a) lecanopagi comprise the ischiopagi and 
pygopagi. The (a) ischiopagi are united by the ischia in such a way that 
the two bodies form a straight line, (a) ischiopagus agonoides (Fig. 402) (the 
adjective signifying no angle); or more rarely the two trunks may be so joined 
at the ischia that they form an angle, (/5) ischiopagus gonoides (Fig. 403). The 
ischiopagi may have four, three, or two lower extremities (tetrapus, tripus, dipus). 
The (b) pygopagi are united by the buttocks, each twin possessing two arms and 
two legs (Fig. 404). (b) The somatopagi (Fig. 405) may have either four or three 
legs, (a) tetrapus, tripus. The (b) somatopagus tripus may have either four or 
three arms (tetrabrachius, tribrachius). (2) In the MonopYgus only the pelvis 
may be single (monolecanus) , or the entire trunk may be that of one individual 
(monosomus, a single trunk body). It is self-evident that the monopygus always 
has only two lower extremities, (a) The monolecani (Figs. 406, 407, 408) 
may have four, three, or two arms (tetrabrachius, tribrachius, dibrachius) 
(b) In the monosomus (Figs. 409, 410, 411, 412), also known as the diproso- 
pus (two faces), as in the case of the cyclopian monster, different degrees of 
approximation of the two heads give rise to corresponding varieties. Thus, 
the monsters may have (a) three eyes (m. triophthalmus) ; (b) four eyes (m. 



DEFORMITIES AND MONSTROSITIES OF THE FETUS. 283 

tetrophthalmus) ; (c) three ears (triotus); (d) four ears (tetrotus); or (e) two 
mouths {distomus). 

2. Hyposchistoi or Dipygi. — The dipygi are divided into two genera: viz., 
(i) syncephalus or fused heads, and (2) monocephalus or single head. 

1. The Syncephali may be united by heads alone, (a) craniopagus (Figs. 413, 
414, 415), or by the head and upper portion of the trunk, (b) hemipagus, half 
united (Fig. 416). The (a) craniopagi may be joined at the forehead, (a) c. 
frontalis (Fig. 413), at the vertices, (b) c. parietalis (Fig. 414), or at the occiputs, 

(c) c. occipitalis (Fig. 415). The (b) hemipagi may be united laterally with 
faces side by side, (a) symprosopus, fused faces (Fig. 416) ; or the junction may be 
back to back or side to back, (6) antiprosopus , faces opposed (Fig. 417). The (a) 
symprosopi (Fig. 416) are described by Taruffi, but are not mentioned by many 
teratologists. Tarum makes three varieties, according as four, three, or two 
eyes are present: («) s. tetrophthalmus, (/5) s. triophthalmus , (r) s. diophthalmus. 
The (6) antiprosopus, long known as the janiceps, may be symmetrical; i. e., 
the two opposed faces may be of the same size and degree of development, 

(a) janiceps symmetricus (Fig. 417); or one face may be normal and the other 
abortive, (/5) janiceps asymmetricus (Fig. 419). In some cases the extremely 
rudimentary character of the abortive face gives the monster the appearance 
of a monocephalus. 

2. The Monocephalus, or Dilecanus (two pelves), is of two species. The 
head and upper part of the trunk may be single, the monsters having but two 
arms, (a) monocephalus dibrachius . The (a) monocephalus dibrachius may have 
two, three, or four lower extremities, and is known respectively as (a) m. dipus 
(Fig. 420), (b) m. tripus (Fig. 421), and (c) m. tetrapus (Fig. 422). In the dipus 
there is a duplication of the genitals, or the separation may begin higher up, so 
that three or four arms may be present. This species has the term of (b) mono- 
cephalus deradelphus (united by necks). Its two varieties are known as (a) m. 
tribrachius and (b) m. tetrabrachius. 

3. Amphischistoi. — In this monstrosity the twins are united in front or be- 
hind. In the former case the monster is known as (1) thoracopagus (united 
by thorax, Fig. 425), in the latter as rachipagus (united by spines). The 
latter, however, is largely theoretical, as but one doubtful case is on record. In 
the (1) thoracopagi the bond of union may be of various degrees. The twins may 
be united principally by the ensiform cartilages, (a) xiphopagus (Fig. 425); or 
they may be united by the sternum, (b) sternopagus (Fig. 423); or the area of 
union may extend as high as the neck or face (c) derothoracopagus (Fig. 426); 

(d) prosopothoracopagus (Fig. 427). The sternopagus, a very common form of 
double monster, may have either three or four arms : (a) s. tribrachius (Fig. 425) ; 

(b) s. tetrabrachius (Fig. 423). 

Parasites ; asymmetrical double monsters. 

Our knowledge of the united parasites is in a somewhat confused state. The 
old arrangement of Saint-Hilaire has never been supplanted, and his cumbrous 
and vague nomenclature is still largely in vogue. His original subdivisions are: 
(1) heterotypic, (2) heter alius, (3) endocyma. 

1. Heterotypus. — In (1) heter oty pus the parasite is united to its host in the 
umbilical region. The principal subdivisions are: (2) heter odymus, (3) heter a- 
delphus, and (4) heteropagus, meaningless terms. As far as can be determined, 
and following the nomenclature of the omphalosites, heter adelphus is an acepha- 
lus; heteropagus, an acormus; while heterodymus might be called an apygus 
(breechless) or thorus (provided with a thorax). In acephalus the parasite con- 



284 



PATHOLOGICAL PREGNANCY. 



sists of a trunk and extremities and is inserted into its host by its headless 
trunk. In acormus a trunkless head is similarly inserted, while in apygus 
the parasite has head and thorax and is inserted by the latter. Finally, 
there is a more highly developed parasite than any of the foregoing which is 
analogous to paracephalus anceps, having head, trunk, and rudimentary limbs. 
This is usually referred to as a thoracopagus parasiticus. Ahlfeld also recognizes 
a dicephalus parasiticus which resembles the preceding, but the spine of the 

parasite is united to that of its 
host, as in the symmetrical 
dicephali (Figs. 428 to 431). 

2. Heteralius. — In the sec- 
ond genus of Saint- Hilaire — 
heteralius — the confusion is 
even greater, if possible. By 
this term is meant a parasite 
inserted at any portion of its 
host except at the umbilical 
region. Most authorities de- 
scribe only a few of the more 
striking parasites of this group. 
A second parasitic head united 
to a normal head at the vertex 
is known as (1) craniopagus 
parasiticus ( Fig. 433). A simi- 
lar duplication, known as (2) 
ischiopagus parasiticus (Fig. 
432), is seen at the opposite 
pole of the body. These are 
the only anomalies of this char- 
acter. The condition known 
as (3) polymelus or dipygus 
parasiticus (Fig. 435) consists 
of supernumerary lower ex- 
tremities implanted at various 
situations, such as the head, 
back, buttocks, thighs, etc. 
The individual deformities are 
known respectively as cephalo- 
melus (Fig. 434), notomelus, 
melomelus, etc. The foregoing 
exhausts the number of para- 
sitic monsters having well-de- 
veloped fetal members. 
3. Endocyma. — There still remain formless collections of fetal debris. These 
are of two types, external and internal. The external type comprises the so- 
called polygnathus at the cephalic pole of the body, and the sacro-coccygeal 
tumor at the caudal pole. In polygnathus tumors composed of fetal debris are 
attached to various portions of the face, forehead, palate, basis cranii, etc. The 
name polygnathus is bestowed on these masses, because the jaws are the chief 
site of attachment. The term polygnathus is wholly misleading, as the de- 
formity is not necessarily an accessory jaw. The (1) sacro-coccygeal tumors (Figs. 
440 and 445) are not all teratomata. The latter, however, represent the debris 




Fig. 445. — Sacro-coccygeal Tumor in a Female 
Fetus Born at the Sixth Month. — {Author's 
collection.) 



ANTENATAL DISEASES OF THE FETUS. 285 

of a parasitic fetus. The internal type of amorphous and undeveloped parasites 
is known as (2) fetal inclusion (Fig. 441). The debris may simply constitute 
a subcutaneous tumor or may be included in many localities within the body, 
including the cranium, mediastinum, abdomen, ovary, testicle, etc. 



(C) MULTIPLE MONSTERS. 

I. TRICEPHALUS. 

Hardly anything is known of this monstrosity, which is, further, the only 
known triple monster. Its existence appears to be authenticated by the illus- 
tration from Fehling (Fig. 442). 



VII. ANTENATAL DISEASES OF THE FETUS. 

I. Injections Diseases. 2. Acute Poisoning. 3. Chronic Poisoning. 4. Dyscrasic Condi- 
tions. 5. Cardiac Diseases. 6. Diseases of the Alimentary Tract, 7. Diseases of the 
Nervous System. 8. Diseases of the Urogenital Apparatus, q. Skin Diseases. 10. Fetal 
Bone Disease. 11. Fetal Traumatisms. 12. Fetal Neo.plasms. 13. General Fetal (Edema. 
14. Maternal Traumatisms. 15. Maternal Uterine Disease Affecting the Fetus. 16. 
Fever in the Mother Affecting the Fetus. 17. Death of the Mother Affecting the Fetus. 

i. Infectious Diseases. — 1. Variola. — When a pregnant woman contracts 
this disease, one of three conditions may result: (1) Pregnancy is inter- 
rupted at the moment of the eruptive period and the woman is delivered of a 
dead or moribund child that has. not been contaminated by the disease. Appar- 
ently there has not been time for the latter to develop. This is the commonest 
termination of pregnancy in a variolous woman. As a variety of the preceding 
there is occasionally noted a termination in which the child survives. This 
occurs when labor sets in during the first onset of the disease and also when the 
type of maternal disease is very mild (varioloid). (2) Pregnancy is not inter- 
rupted by the disease. There is a simple coincidence of labor and the mother's, 
disease which supervenes shortly before term, or the pregnancy is continued 
during and after the subsidence of the disease until term arrives. The children 
which result from these pregnancies are born intact and it is possible to vaccinate 
them successfully. The type of maternal disease in this category must be very 
mild. (3) Pregnancy is interrupted and the child is born with a full variolous 
eruption. These cases are rare, but many have been placed on record. In a 
few the eruption did not appear until a few days after delivery. The most 
remarkable of all cases of intrauterine variola are seen in twin pregnancies in which 
one twin is born intact while the other has variola. Kaltenbach has even reported 
a case of triplets in which two of the children were born with smallpox while the 
third was healthy. Vinay regards this as open to a very simple explanation. 
A healthy placenta, he states, does not allow disease germs to pass through it. 
When, however, this organ is the seat of infarcts or other lesions, the natural 
barrier is overcome. (4) To the preceding categories a fourth may be added; 
here, while the mother is not known to have had variola, although there may be 
a history of exposure, her pregnancy is interrupted and the fetus is found to have 
smallpox. In one such case the mother had had intercourse with a variolous 
convalescent who was probably the father of the child. This woman was doubt- 
less protected from the disease by vaccination. Vinay is inclined to believe that 



286 PATHOLOGICAL PREGNANCY. 

the maternal immunity in these latter cases is more apparent than real; for in all 
the recorded instances of variolous pregnancies in healthy women the latter have 
exhibited headache and backache at the time when the fetus should have been 
contracting the disease. The mother therefore suffers from the rare form of the 
latter known as variola sine exanthema, in which the entire eruption may be 
absent, escape observation, or consist only of a few pustules. Symptoms: 
There is absolutely no method by which we can determine the incubation 
period of fetal variola. The localization of the disease differs considerably from 
that in the adult, for the face is often spared while the trunk is likely to bear the 
brunt of the eruption. The eruption may be discrete or confluent, and the 
disease may actually run its course in utero, so that the child is born with cica- 
trices only. The lesions are umbilicated, but do not, of course, form crusts in a 
moist medium. When the fetus is first attacked in utero, it betrays its distress 
by violent movement. Prognosis: Intrauterine variola is fatal in the great 
majority of instances. Examples under which recovery occurs have already 
been cited. The child is not necessarily still-born, for it may survive for 
some days. Survrving children are sometimes susceptible to vaccination, but 
in other cases are refractory. Treatment: There is no indication for thera- 
peutic abortion and no management which can be directed especially to the 
fetus. All pregnant women should be vaccinated when smallpox is prevalent. 
For treatment of the mother, see Section XV. 

2. Vaccinia. — The child borne by a woman who had smallpox during 
her pregnancy may or may not be susceptible to vaccination. Those who are 
immune give no evidence of having had fetal variola. Vaccinia can be 
transmitted to the fetus. Many women are vaccinated during pregnancy and 
their infants have the same experience soon after birth. The results of different 
authorities vary somewhat, but, according to Ballantyne, about 33 per cent, of 
infants are in this way rendered immune. Individual observers place the per- 
centage of immunity as high as 60 per cent, and even 80 per cent. This in- 
herited refractoriness to vaccination is short-lived, so that such infants should 
by all means be vaccinated as soon as a positive result is obtainable. The 
claim has been made that unsuccessful vaccination of the mother often confers 
some immunity on the fetus. 

3. Measles. — When a pregnant woman contracts measles, gestation is 
usually interrupted (in about 75 per cent, of cases, according to limited figures). 
Children thus born may present a morbillous rash and coryza. Ballantyne, 
who has seen an undoubted instance of intrauterine measles, cites some twenty 
others from literature. In each of these the mother herself presented the symp- 
toms of the disease. 

4. Scarlatina. — Pregnant women often contract this disease, and may 
or may not abort. Ballantyne has reported an undoubted case in which 
the premature infant of a scarlatinous mother was seen to have a rash and en- 
larged glands on the first day post partum. According to this author, there are 
about a score of such cases recorded. Vinay also states that healthy children 
have been born of scarlatinous mothers who have afterward infected the off- 
spring by lactation. In my own case in private practice, scarlatina in the 
mother resulted, immediately upon the appearance of the eruption, in a 
seventh-month miscarriage of a dead fetus, the latter showing no evidence of 
the disease. 

5. Erysipelas. — The possibility of the occurrence of fetal erysipelas 
having been established by certain obstetricians (Kaltenbach, Runge, Stratz), 
Lebedjeff succeeded in demonstrating the presence of Streptococcus erysipe- 



ANTENATAL DISEASES OF THE FETUS. 287 

latis in the chorion. Erysipelas in the mother is not often transmitted to the 
fetus, and causes abortion in about 50 per cent, of all pregnancies. According 
to Hofmeier, the fetus exhibits tachycardia when the mother is attacked by the 
disease, the pulse-rate varying directly with the mother's temperature. Certain 
authorities have surmised the existence of fetal erysipelas upon the following 
grounds: The mother having experienced an attack two weeks before term 
without interruption of pregnancy, the child upon its appearance was found to 
be undergoing desquamation. This evidence is necessarily inconclusive. 

6. Diphtheria. — Nothing is known of intrauterine diphtheria. While newly 
born children have doubtless been contaminated by diphtheritic mothers, it is 
doubtful if a genuine case of congenital transmission has ever been recorded. 

7. Typhoid Fever. — Fetal typhoid is a well-established example of ante- 
natal disease, and has been known since 1840. While the older cases were 
recognized by the characteristic intestinal lesions, the fetus, as a rule, does not 
present this localization. After the discovery of Eberth's bacillus diagnosis 
of fetal typhoid became easier, and still another impetus has been received from 
the Widal reaction. Pregnant women who contract typhoid fever exhibit a 
high percentage of interruption of pregnancy, statistics giving the frequency as 
from 58 to 83 per cent. (Vinay). Children born of typhoid mothers are mostly 
premature and have a high secondary mortality. Those who survive are delicate 
and predisposed to various structural and functional anomalies, just as are the 
offspring of the tuberculous, syphilitic, alcoholic, etc. The study of typhoid 
fetuses since the discovery of Eberth's bacillus does not appear to show that the 
latter causes many lesions, although it is found very widely distributed. In 
other words, the fetus is the seat of a pure typhoidal sepsis in the majority of 
cases. Widal's test applied to the fetal blood has given positive results, showing 
that the antitoxic as well as the toxic principle passes through the placenta. 
Aside from the occasional occurrence of true typhoid lesions in the fetus, and 
the common occurrence of a bacillemia or pure sepsis, it is believed by recent ob- 
servers that the toxins of the disease cause slight but important structural alter- 
ations in the fetal viscera, and also retard metabolism and reduce the body- 
temperature, so that the child, if it grow up, will exhibit dystrophic stigmata, 
mental peculiarities, deafness, etc. Since the high temperature of typhoid is 
responsible in part for the frequency with which pregnancy is interrupted, it has 
been supposed that the Brand method of treatment would reduce this rate. 
Statistics, however, show very little improvement in this respect. 

8. Cholera. — According to Vinay, this disease exerts a more disastrous 
influence upon pregnancy than any other, variola not excepted. Analysis of 
many cases shows 53 per cent, of interruptions in which the children are in- 
variably still-born. According to Slavjansky, the placenta exhibits character- 
istic alterations, due in turn to a specific metritis. Tizzoni and Catani found the 
comma bacillus in the fetal tissues. The child is invariably expelled shortly 
after its death, apparently because of the oxytocic action of the cholera virus. 
Many mothers, however, must die undelivered. Those who survive and whose 
pregnancies are not interrupted have borne healthy children. Ballantyne 
cites several instances in which newly born infants were already infected 
with cholera, although Tarnier taught that intrauterine transmission did not 
occur. 

9. Malaria. — The possibility of fetal paludism has been extensively ques- 
tioned, but is now generally admitted. Children with enlarged spleens and 
other evidences of paludism have been born to malarial mothers. The most 
recent authorities dispute the claim that plasmodium malariae has ever been 



288 PATHOLOGICAL PREGNANCY. 

found in the fetal tissues. Evidence afforded of intermittent fever in the 
newly born is open to criticism, because such infants may have been bitten by 
infected mosquitos soon after birth. Practically, therefore, the diagnosis must 
be based upon the presence of congenital hypertrophy of the spleen, associated 
perhaps with dropsical accumulations, extra vasated blood, discolored skin, and 
pigmented white blood-corpuscles. Such children exhibit, in addition, sub- 
standard weight, debility, wrinkled skin, pallor, etc. It has been claimed that 
children born of malarious mothers exhibit almost constant defects in length 
and weight in comparison with those born of healthy mothers. There is also a 
very high percentage of interruptions of pregnancy in malarious women, though 
abortion is not common. Vinay has collected notes of 158 pregnancies with 120 
interruptions (about 76 per cent.); but of this number there were but 20 abor- 
tions, the remainder representing premature deliveries. Hence, statements 
which relate to small size and debility of the newly born may be explained largely 
by prematurity. Intrauterine malaria should be amenable to quinine exhibited 
to the mother, but this remedy has acquired a bad reputation in malarious coun- 
tries as an abortifacient. Although many eminent clinicians deny that quinine 
given in medicinal doses has any effect upon the pregnancy, others go to the 
opposite extreme and attribute the high percentage of premature births to this 
drug alone. The soundest opinion appears to be as follows : Malaria has, per se, 
a marked tendency to bring on delivery ahead of time, and since quinine is a 
specific for the disease, the good it may do will greatly outweigh the prospect of 
an occasional assertion of an oxytocic action. 

10. Influenza. — Epidemic influenza is responsible for many premature 
births ; failure of such children to survive should not be attributed to congenital 
transmission when we bear in mind the high mortality of prematurity in general. 
In regard to the possibility of actual transmission of the disease, Ballantyne 
states that he has had several personal cases of influenza contracted in utero. 

11. Fetal Sepsis. — If the mother is in a state of sepsis from pneumo- 
cocci, streptococci, staphylococci, and Bacillus coli, and the placenta allows 
them to pass into the fetal circulation, a condition of intrauterine sepsis neces- 
sarily results, and some of the fetal organs will probably be attacked. Pneumo- 
coccus sepsis, fetal pneumonia: It does not follow that a pneumococcus sepsis 
of the mother, preceded by or associated with pneumonia, will be localized in 
the fetal lung. Neither is it necessary that fetal pneumonia be derived from the 
maternal disease. Pregnant women with pneumonia frequently abort, and, 
according to Vinay, 60 per cent, of their infants born alive die shortly after 
birth, presenting at autopsy evidences of pulmonary hepatization. The sooner 
delivery can occur after the mother is attacked, the more likely are the children 
to survive. The claim that these alterations in the lung are pneumonic has been 
disputed in the belief that the fetus undergoing air-hunger from the maternal 
pneumonia attempts inspiration and aspirates amniotic fluid, as a result of which 
the lung presents a characteristic appearance at autopsy. Admitting the proba- 
bility of this claim, it is still certain that fetal pneumonia may occur as a feature 
of pneumococcus sepsis. Streptococcus sepsis: Streptococcus pyogenes has been 
found in the blood and tissues of the fetus in connection with various fetal 
diseases of the mother. Most recorded cases appear to be examples of pure 
sepsis without lesions. The streptococcus of erysipelas appears to have caused 
fetal endocarditis and other lesions, and Moncorvo thinks that congenital ele- 
phantiasis may originate in this way. Staphylococcus sepsis: The staphylococ- 
cus has been found in fetal tissues in a case of typhoid fever. If acute articular 
rheumatism, as has been claimed, is due to the staphylococcus, the few recorded 



ANTENATAL DISEASES OF THE FETUS. 289 

cases of fetal rheumatism may be cited in this connection. Bacillus coli sepsis: 
Ballantyne states, without references, that Bacillus coli has been found in the 
fetus. 

12. Miscellaneous. — Anthrax has been transmitted from the mother to 
the fetus in a few instances, the bacillus of the disease being recognized in 
the fetal tissues. Hydrophobia is transmissible by animal experiment, but 
fetal hydrophobia in mankind has never been described. Tetanus: We know 
of no case of association of tetanus in the mother with trismus in the newly 
born. Naturally, in the vast majority of recorded cases of the latter the fetus 
was not exposed to infection from the mother. Yellow fever: Pregnant women 
with this affection often abort. When they recover without miscarriage, the chil- 
dren afterward born are said to be immune to the disease. This statement, made 
upon the authority of individual observers, is not generally credited. Relapsing 
fever is known to be transmissible to the fetus. According to Kleinwachter, 
there is a fetal typhus. Ballantyne mentions a fetal varicella. Kleinwachter 
mentions fetal epidemic parotitis. Fetal pertussis is mentioned by Ballantyne. 
Of epidemic cerebrospinal meningitis a single case is on record (Ballantyne). 

13. Tuberculosis. — When a consumptive woman becomes pregnant, she 
tends to abort in proportion as the disease is advanced. Thus, it has been 
computed that about 15 per cent, of abortions occur in the first, and 3$ per 
cent, in the second, stage of phthisis. When the pregnancy is not interrupted, 
the offspring of these women are usually delicate and undersized, and after 
developing the so-called strumous or tuberculous diathesis, they tend to fall a 
prey to the disease. Before the discovery of the infectious character of tuber- 
culous matter and the specific germ of the disease, it was generally believed that 
the phthisical individual practically acquired the disease in utero. The apparent 
relative immunity of the fetal and placental tissues toward direct implication in 
the tuberculous processes has, however, led to the conviction that antenatal 
infection is a mere curiosity in pathology, and that the mother transmits to her 
fetus nothing more than a lack of resistance to disease. There is a species of 
fetal tuberculosis that may be of common occurrence. The toxic products of the 
disease, circulating in the maternal blood, should certainly be able to enter the 
fetal vessels, and there give rise to a train of symptoms similar to those which 
follow injections of tuberculin in large doses. It can hardly be doubted that 
exposure to this influence often causes fetal death, especially in the later months 
of pregnancy ; while those children who do not die in utero exhibit at birth the 
delicacy and undersize already mentioned. The fact that bacilli are seldom 
found in the blood of tuberculous individuals, and then, as a rule, only in miliary 
tuberculosis, furnishes a strong argument against the existence of bacillary 
emigration from the mother to the fetus even if the placenta were permeable. 
From all that has been said it appears that the notion of fetal tuberculosis is best 
considered under two heads: (1) Tuberculous toxemia, and (2) actual tuber- 
culosis of the fetus. 

Tuberculous Toxemia. — We must assume that this affection is very common — 
almost the rule — in the fetuses of tuberculous women. It is not in itself a tuber- 
culosis ; indeed, the claim has been made by those who believe in the efficacy of 
tuberculin therapy that the fetus acquires a certain degree of immunity from this 
experience. This is a repetition of the old claim that the scrofulous child is pro- 
tected from the more deadly phases of tuberculosis. The statistics of Bourgeois 
(cited by Vinay) appear to show the hollowness of such claims ; for of sixty-nine 
children born of women in advanced phthisis, every one eventually died of tuber- 
culosis. Numerous authors see in the tuberculous toxemia the simplest explana- 
19 



290 PATHOLOGICAL PREGNANCY, 

tion of the extraordinary susceptibility to the disease in the child with this 
exposure. Owing to the cessation of menstruation in the tuberculous, together 
with the deliberate intent of avoiding conception in this condition, pregnancy 
is somewhat rare as a general rule in women with advanced phthisis, although 
common in rapid cases. Our knowledge of this specific fetal toxemia is some- 
what scanty, and we must judge of it largely from analogy. There is little 
doubt that such a condition constitutes an indication for the interruption of 
pregnancy. (See Section XIII.) 

Actual Fetal Tuberculosis. — This condition has been recognized a very few 
times only (between twenty and thirty). There are two distinct types: viz., 
simple bacillosis without lesions, and tuberculosis proper. In the former the 
fetal tissues are shown to contain bacilli by the microscope, by culture, or 
by animal inoculation. In the latter tubercles are recognizable. Accord- 
ing to some authors, the lesions are almost necessarily located in the organs 
first traversed by the placental blood, especially the liver and spleen. This 
claim remains to be proved, as a great variety of organs may be attacked 
by the disease. In some of the cases the placenta or endometrium - ; was also 
tuberculous, but there is no necessary relationship in this particular. 

The great infrequency of fetal tuberculosis is to be explained as follows: 
Cases are undoubtedly overlooked, and some pediatrists — Holt, for examples- 
are inclined to look upon cases of tuberculosis in extremely young children as of 
fetal origin. But even with this concession the disease is notably rare, because 
two conditions are doubtless indispensable factors in its production: (i) The 
mother must be suffering from general miliary tuberculosis, otherwise her blood 
will contain no bacilli; and (2) the placenta must be the seat of some alteration 
whereby the bacilli are suffered to enter the fetal blood. 

The possibility that fetal tuberculosis may be derived from a tuberculous 
ovum, or even infected spermatozoa, has been subjected to experimental testing 
in animals. Paternal infection has been deemed impossible, but contamination 
through the ovum is regarded as a possibility. Tuberculosis of the ovary is now 
known to occur frequently, and in some cases the disease has even appeared to 
attack the Graafian follicles by preference. As to the fate of an ovum proceed- 
ing from such a follicle we can only make conjectures. Statistics appear to 
show that early abortion occurs very rarely in tuberculous women, but these 
figures are based on pulmonary phthisis only. Genital tuberculosis is, of course, 
a different type of disease. 

14. Syphilis. — Fetal syphilis — i. e., syphilis which asserts itself during 
the fetal period for the first time — must be distinguished from syphilis 
which is contracted perhaps during fetal life, but on account of the prolonged 
incubation period does not assert itself until after delivery — usually not until 
the second month of extrauterine life. We know little of germinal and embry- 
onal syphilis. Antenatal syphilis, then, is to-day synonymous with fetal 
syphilis. The effects of the syphilitic poison or poisons upon the fetus are, 
speaking broadly, the same as those seen in adult life: viz., specific and non- 
specific, or, in other words, syphilitic and parasyphilitic. The latter changes in 
the fetus are essentially dystrophic, and comprise a long series of modifications 
of development in various organs and tissues. All the structures which make 
up the ovum may be attacked by the disease — fetus, liquor amnii, membranes, 
cord, and placenta. The specific alterations induced by fetal syphilis are, in 
brief, as follows: Liver: While this may escape injury, it is very commonly 
affected, being enlarged and hardened and strewn with whitish dots. These 
changes are the results of a diffuse interstitial cirrhosis, the white granules con- 



ANTENATAL DISEASES OF THE FETUS. 291 

sisting of miliary gummata. Larger gummy nodules are seldom seen in the fetal 
liver. Lungs: These are often the seat of interstitial pneumonia and miliary 
gummata, the changes being analogous to those found in the liver. The so-called 
white pneumonia which is sometimes encountered consists of patches of air-cells 
filled with epithelial debris in a state of fatty degeneration. Heart and Vessels: 
The heart is seldom attacked beyond the deposition of a few miliary gummata, 
but the vessels are usually the seat of generalized periarteritis and endarteritis 
with resulting obstruction of the lumina of the vessels attacked. Thymus: The 
lesions of this organ, largely cystic, do not appear to be specific in character. 
Kidneys: These organs are not usually implicated by the disease. When in- 
volved, they are increased in size and weight and are the seat of more or less 
interstitial inflammation, in which the blood-vessels participate. The paren- 
chyma undergoes some degenerative alterations. Intestines: Fetal peritonitis 
is largely of syphilitic origin. Osseous System: The diaphyses and epiphyses of 
the long bones are separated by a peculiar linear tract which is of varying 
breadth, yellow, and irregular (Wegner's line). This formation represents the 
occurrence of syphilitic osteochondritis. The peculiar color is due to the fatty 
or cheesy metamorphosis of the products of inflammation. Integument: The 
bullae of pemphigus of the newly born may develop in utero as a part of the fetal 
evolution of the disease. This is also true to a limited extent of moist papules, 
condylomata, etc. A pseudo-ichthyotic condition of the skin representing 
extensive desquamation is sometimes seen. The changes which occur in the 
fetal appendages are described under the disease of the latter. 

The non-specific affections or dystrophies, while formerly regarded as char- 
acteristic of fetal syphilis, are now believed to differ in nowise from those 
which prevail in the fetuses of women who suffered during their pregnancies 
from chronic diseases, alcoholism, privation, and the like. They include every 
phase of malformation from the so-called stigmata of degeneracy up to capital 
malformations and monstrosities. The wrinkled skin and senile look are mere 
indications of prematurity or congenital weakness, and the maceration which 
occurs after death of a syphilitic fetus is probably the same process seen after 
fetal death in general. The most that can be said is that syphilis is a frequent 
cause of antenatal dystrophy, and that many malformations are found in syph- 
ilitic fetuses. 

Transmission. — There is no necessary connection between the date upon 
which the germ first attacks the fetal tissues and the period of an explosion of 
symptoms. The fetus may contract the disease, but it may be the newly born 
or older infant who first exhibits the specific lesions. Or the ovum may contract 
the disease and the fetus suffer from it. In describing fetal syphilis we must 
confine ourselves largely to the outbreak itself. We must also bear in mind the 
non-specific lesions from which the fetus may suffer, (i) To take the most 
familiar conditions conceivable in this connection, let us suppose that a woman 
some months pregnant undergoes an explosion of secondary syphilis of a severe 
type. The placenta is .attacked along with most of the other tissues of the body, 
and the fetus dies before it could have time to share the maternal disease. This 
is the most common type of the relations which subsist between syphilis and the 
fetus, and corresponds to the great frequency of abortion and miscarriage in 
syphilitic women. Children born under these circumstances should have nothing 
peculiar in their appearance. (2) If the fetus is not killed outright, it is almost 
certain that the germs of the disease will traverse the placenta and set up some 
of the visceral changes which have already been indicated. Unless this infec- 
tion occurs near term, a fetus thus rendered profoundly syphilitic is very 



292 PATHOLOGICAL PREGNANCY. 

likely to die in utero from the disease itself; and when expelled, it will present 
a typical picture of fetal syphilis, including maceration. If such a child is born 
alive but hopelessly diseased, we have the so-called syphilis neonatorum, which 
should not be confounded with infantile syphilis proper, which represents the 
outbreak of an infection received in utero. (3) If the germs of the disease do 
not traverse the placenta, at least at the outset, the fetus is exposed to the toxic 
principle of the disease as it circulates through the maternal blood, and, even 
aside from this, it must perhaps suffer to some extent from the anemia and mal- 
nutrition of the mother which are due to the action of this poison. Directly 
and indirectly, then, the fetal development is more or less interrupted, just as it 
would be in tuberculosis, alcoholism, etc. The fetus maybe born in this condi- 
tion alone, or, as is much more likely, — at least early in the maternal disease, — 
some of the maternal germs finally penetrate the placenta. The fetus when 
born is found to be small and feeble, with certain evidences of prematurity, not 
yet syphilitic perhaps, but containing the germs of the disease. After several 
weeks of extrauterine life the disease becomes active, and the usual pheno- 
mena of secondary syphilis develop. This is the familiar type of congenital, 
hereditary, or infantile syphilis. In some cases the activity does not occur 
until late in childhood or even until adolescence (tardy hereditary syphilis) ; such 
individuals are peculiarly afflicted with the evidences of dystrophy of syphilitic 
origin. (4) As intimated, it is possible for a fetus to escape bacillary infection 
in utero, and develop no syphilitic lesions in after years, although the child may 
present evidences of dystrophy. (5) Finally, it is possible for an infant to escape 
syphilis in utero altogether — not only its specific but non-specific influence. All 
the preceding types may occur in the pregnancies of one woman. It is impos- 
sible in a work of this sort to enter into the discussion of such subjects as direct 
paternal infection, syphilis of the unimpregnated ovum, infection of the mother 
from the fetus, immunity, Colles's and Profeta's laws, etc. Syphilis contracted 
before or near the time of conception is said to be more generally fatal to the fetus 
than when the mother is infected some weeks or months after impregnation has 
occurred; that is, the proportion of abortions and of fetal syphilis will be higher 
in the former case. 

Treatment. — The mother of course requires treatment for syphilis, and there 
is no special indication for the fetus. Mercury and potassium iodide should be 
given as early as possible and continued throughout pregnancy. Very recently 
an attempt has been made to treat the fetus locally by the use of medicated 
tampons introduced into the vaginal vault. The mercury was used in the form 
of ointment, mixed with an equal or a double quantity of cocoa-butter (Riehl). 
In theory a special indication should exist for the fetus when a syphilitic husband 
has impregnated his wife. In these cases the fetus is supposed to infect its 
mother, and proper local medication might prevent this catastrophe if it really 
ever occurs. Riehl's method would be applicable here, but a more rational 
treatment would be to empty the uterus at once. In regard to the routine prac- 
tice of abortion in syphilis, the chance of curing the fetus. is so considerable that 
it is contraindicated as a general resource and is indicated only under special 
contingencies. 

2. Acute Poisoning. — Chloroform: There is no longer any doubt that chloro- 
form used as an anesthetic in labor tends to cause fetal asphyxia. This is demon- 
strated by the results of Caesarean section, and is, in fact, something of a con- 
traindication to the use of anesthesia in labor. Chloroform has never been 
recovered from the fetal blood. Fehling believes that it can determine the 
presence of fetal icterus and albuminuria. Ether: What has been said of chloro- 



ANTENATAL DISEASES OF THE FETUS. 293 

form applies equally well to ether. (See Anesthesia in Obstetrics, Part X.) 
Coal-gas: The pregnant woman sometimes inhales this gas with or without 
suicidal intent. In cases in which the mothers escaped death they sooner or 
later were delivered of dead or macerated children. This gas is extremely poi- 
sonous to the fetus. Nevertheless there is no evidence that the gas enters the 
fetal circulation to any extent. Alcohol: Cases are upon record in which the 
ingestion by pregnant women of an inordinate amount of alcohol has apparently 
caused fetal death. Mineral Acids: In cases of acute poisoning with sul- 
phuric acid the fetus appears to have shown some of the dehydrating action of 
this substance, but only in its skin, which was hard and brown. Metalloids: 
In phosphorus-poisoning the fetus shows very much the same lesions as the 
mother, it being certain that this substance passes through the placenta. In 
acute arsenical poisoning, however, the ovum gives no evidence that this drug 
reaches the fetal tissues. 

3. Chronic Poisoning. — Plumbism: In pregnant women suffering from 
chronic lead-poisoning abortion occurs in no less than 60 per cent, of cases, and 
children born alive have a high secondary mortality and exhibit a marked ten- 
dency to convulsions and hydrocephaloid or rachitiform malformations of the 
head. The latter inheritance may even proceed from the father alone. When 
both parents are affected, the child morbidity is increased. It is not known to 
a certainty whether the lead kills the fetus outright or simply excites labor. The 
metal has been found in the fetal viscera, where it has apparently set up inflam- 
matory disturbances. On the other hand, preparations of lead have a notorious 
tendency to produce abortion, and are much used with this criminal intent. 
Mercurialism: In pregnant women who are subject to chronic mercurialism the 
tendency to abortion and premature delivery is high, although the exact ratio 
is unknown. When syphilis is present, large medicinal doses of mercury are 
known to prevent abortion. The metal has been found in the fetal tissues. A 
curious fact repeatedly noted is the improvement in health which follows preg- 
nancy in these cases. Thus, a worker in a mirror or barometer factory may have 
her salivation, tremor, etc., disappear after conception, to return when abor- 
tion has occurred. This apparent protecting action of the embryo suggests 
Colles's law of maternal immunity in syphilis. The action of mercury upon 
pregnancy seems to be less severe than that of lead. Phosphorism: De Caulbry, 
Borri, and others state that pregnant workers in match factories undergo abor- 
tion very frequently. But few data are available regarding chronic phosphorus- 
poisoning. Arsenicism: We know even less of arsenic than of phosphorus in 
regard to the effects of chronic maternal poisoning upon the fetus. Alcoholism: 
It was not until 1900 that Nicloux* was able to demonstrate that the drug in 
question enters the fetal circulation. He gave a woman milk-punches after she 
was well along toward delivery, and was able to distil some of the alcohol from 
the blood of the umbilical vein. In regard to the effects of alcoholism on preg- 
nancy, as studied in a series of chronic drunkards,! there is no evidence of any 
strong tendency to abortion. Still-birth is quite common, but the principal 
effect of alcohol upon the fetus is shown in the extraordinary tendency to ner- 
vous and cerebral disease, malformation, and degeneracy exhibited by these 
children as they grow up. Alcohol in the fetal circulation tends to arrest the 
highest development. Morphinism: In pregnant morphinomaniacs no especial 
tendency to abortion or premature delivery has been noted. The children born 
to such women often appear healthy in every respect. Morphin, however, 
has been recovered from the fetal tissues. There is considerable evidence 

* " L'Obstetrique," 1900, t. v. f Sullivan : "Jour. Mental Science," 1899. 



294 PATHOLOGICAL PREGNANCY. 

that the fetuses are more likely than others to require resuscitation at birth. 
I have observed that attempts at withdrawal of the morphin during gestation 
have been followed by excessive fetal movements, which again subsided when 
the use of the drug was renewed. This phenomenon suggests that the fetus has 
acquired a tolerance to the narcotic. Nicotinism: The pregnancies in many 
tobacco factories, etc., are not interrupted, although there is a very high mor- 
tality among the children of these women. 

4. Dyscrasic Conditions. — Diabetes: Fetal diabetes is not actually known to 
exist, but the sugar in the maternal blood may be able to pass into the circula- 
tion of the fetus and give rise to various disturbances. Sugar has been found 
in the amniotic fluid in cases of diabetes, and also in the urine of the new-born. 
Artificial (phloridzin) glycosuria in the mother causes sugar to appear in the 
fetal urine. According to Vinay, pregnancy in diabetic women is interrupted 
in over a third of the cases, while about one-half of the children born alive do not 
survive; but this need not be due to the sugar directly, because diabetes often 
leads to disease of the endometrium. Albuminuria, Renal Disease, Toxemia of 
Pregnancy, Eclampsia of the Mother: The children are often still-born or die 
soon after birth. All in all, the chance of survival of these children is very 
small. They are undersized and below weight, even when fully matured. 
They are very prone to be seized with convulsions after birth, and, according 
to some, even in utero. Autopsies upon many of these fetuses have revealed no 
constant pathological changes. In fact, the obscurity which attaches to the 
entire problem of eclampsia, etc., in the mother extends to the fetus. (Compare 
Section X, Part III.) Leukemia: Women with this affection seldom become 
pregnant. In the few recorded cases the infant was sound. Cancerous Ca- 
chexia: Still-births are very common, while children born alive are very weakly 
and in many cases succumb soon after birth. The toxins which must be present 
in the maternal blood appear to exert an action on the fetus which is similar 
to that observed in tuberculosis. 

5. Cardiac Diseases. — Many women with heart disease are able to bear per- 
fectly sound children. On the other hand, the condition of an asystolic woman 
must to a certain extent influence her fetus, causing interruption of pregnancy 
in some cases, while living children are delicate either per se or as a result cf pre- 
maturity. Since placental stasis and edema and hydramnios result from 
heart disease, it is difficult to understand how the fetus could fail to be com- 
promised. Endocarditis : This affection appears to be very common in fetal life. 
Its presence is revealed by changes analogous to those of the same disease in 
extrauterine life: viz., thickening of the endocardium, contraction of the orifices, 
and valvular lesions. The causes are very obscure. One would naturally ex- 
pect to find some infectious or toxemic state of the maternal blood to account 
for it, but the mother often appears in perfect health. Doubtless some of these 
cases are due to placental infection, although Ballantyne speaks only of maternal 
erysipelas and tuberculosis as having led to fetal endocarditis. If the disease 
is of fetal origin, its nature is extremely obscure, as is the relation of endocardi- 
tis to congenital malformation of the heart which reverts chiefly to the embryonal 
period. The clinical features of this affection are as interesting as its path- 
ogeny is obscure. It has been diagnosticated a number of times during intra- 
uterine life through auscultation of the fetal heart, systolic murmurs having 
been readily apparent. Auscultation after delivery gave the same sounds in 
living children, while autopsy confirmed the diagnosis in the case of non-survival. 
The presence of a uterine souffle under these circumstances might readily pro- 
duce an illusion. As with so many other presumably fetal diseases, it appears 



ANTENATAL DISEASES OF THE FETUS. 295 

quite probable that what is called fetal endocarditis represents an embryonal 
anomaly. Fetuses with this affection are very prone to exhibit one or more 
malformations of other tissues (hare-lip, cleft palate, imperforate anus, horseshoe 
kidney, Mongoloid idiocy, etc.)- Atheroma: At least one case of atheroma of 
the aorta and pulmonary artery is known. The fetus was premature and sur- 
vived about two weeks. It is hardly possible for such a condition to develop 
in so short a time after birth. 

6. Diseases of the Alimentary Tract. — Ascites: As a rule, this condition is due 
to fetal peritonitis, and is thus a result of disease. It is considered to some 
extent under dystocia of fetal origin. Peritonitis: This disease is usually, but 
not necessarily, accompanied by effusion (see Ascites). The adhesions which 
form may cause various late malformations in the abdominal cavity. The 
affection is said to be very common, and has been regarded in the past as one 
of the principal causes of fetal death; but as all peritoneal effusion is not neces- 
sarily inflammatory, we cannot be assured of the truth of these claims. Fetal 
peritonitis may be due to hydramnios or syphilis, but in very many cases appears 
to have arisen idiopathically or from unknown maternal causes. Congenital 
Obliteration of the Bile-ducts: This interesting affection is one of the best exam- 
ples of the diseases of the fetal period. It appears to be analogous to biliary 
cirrhosis of the liver in adult life. The initial process, the nature of which is 
unknown, leads to obstruction of the biliary passages, which is accompanied or 
followed by cirrhosis of the liver and jaundice. The fetus is born with icterus, 
and the condition is thus one of icterus neonatorum, under which name it is fully 
described (Part IX). Congenital Hypertrophic Stenosis of the Pylorus: This 
belongs clinically under the diseases of the newly born, but undoubtedly arises 
in titer o. It possesses a nervous or spasmodic element which precedes or is asso- 
ciated with hypertrophy of the pylorus and the wall of the stomach. Something 
analogous to this union of nervous spasm and hypertrophy is seen in the urethra 
and bladder, also the colon. Miscellaneous: Ballantyne, in addition to the con- 
genital hypertrophy of the colon, speaks of a congenital volvulus. 

7. Diseases of the Nervous System. — Congenital Internal Hydrocephalus: If 
this affection is due to an inflammation of the ependyma, it is a fetal disease; 
but if, as is probably the case, it is an effusion of fluid in connection with some 
anomaly of development in the embryonal period, its consideration belongs 
elsewhere. In any case it is described to some extent under " Dystocia of Fetal 
Origin" (Part V), and also under "Malformations," page 273. It may also be 
properly considered among diseases which affect the newly born (Part IX). 
Cerebral Diplegia: While congenital spastic rigidity, or Little's disease, is 
usually held to have an intra-partum origin, it is by no means certain that there 
is not in some cases an antenatal element. Chorea: This affection can some- 
times be diagnosticated ante partum through the choreic movements of the 
fetus. In such cases we often find antecedents which might in part account for 
the affection, such as history of maternal fright or fall, alcoholic or epileptic 
inheritance. But chorea is sometimes hereditary, and even a distinctly family 
malady, which peculiarity has been remarked in some of these intrauterine 
cases. A distinctly hereditary affection has nothing to do with the fetal stage 
of intrauterine life, hence chorea from this standpoint could not be placed 
among fetal diseases. The same is true of such affections as Friedreich's 
ataxia, Thomsen's disease, etc. Maternal Impressions: The nervous system of 
the mother is easily excited, a very slight irritation being capable of arousing 
contractions of the uterus. The effects of disturbances of the maternal 
nervous system on the fetus are probably most common in the case of women 



296 PATHOLOGICAL PREGNANCY. 

with highly developed nervous organizations. The modus operandi of these 
phenomena is not yet clearly understood. Although there is no apparent 
nervous connection between mother and child, there may be an alteration in the 
blood caused by profound nervous disturbance analogous to the decomposing 
effect of an electrical current on a chemical solution. This view would be some- 
what supported by the well-known fact sometimes observed in women whose milk, 
as a result of strong emotion, becomes a rank poison to the child. Maternal impres- 
sion is as yet a mooted question, and reliable literature on it is deplorably defi- 
cient. However, much has been written on both sides, and arguments and exam- 
ples have been brought forward which, in their turn, would almost seem to prove 
the opposed views. The affirmative side of the subject has been espoused from the 
earliest historical period. Instances pointing to the connection between or the 
dependence of congenital deformities, both physical and mental, upon maternal 
impressions are too numerous to be completely dismissed as coincidences. On 
the other hand, two of the strongest arguments opposing this view have been 
advanced as : ( i ) the lack of nervous connection between mother and fetus and 
(2) the alleged cause of the anomaly generally takes place at a period not coinci- 
dent with that of the embryonic evolution of the part affected. The whole 
subject is at present in an uncertain state. Hereditary Predispositions of the 
Fetus: Syphilis with its effects on the fetus has already been noticed. There 
are certain deformities which belong to certain families as an inheritance ("recur- 
rent deformities"). These may be serious enough to cause death. One strange 
affection that has been noted is the thickening of the fibrous and muscular tissue 
of the umbilical vein, which diminishes the calibre to such an extent that several 
fetuses affected in this way were born dead. They belonged to the same mother 
(Leopold). 

8. Diseases of the Urogenital Apparatus. — Nephritis: In dropsy, anuria, etc., 
of the newly born the question of the existence of intrauterine nephritis naturally 
arises. Cases in which the children thus affected are born alive have thus far 
been inadequate for the solution of the problem. Thus, in an observation cited 
by Ballantyne the child did not become dropsical until the second day after 
birth. It survived three weeks. The existence of fetal nephritis must be 
determined largely from a study of unborn or still-born children. Vesical Dis- 
tention: This is also considered among the causes of dystocia of fetal origin 
(Part V). In any case it is hardly a fetal disease nor due to a disease, but 
rather a condition associated with various malformations, some of which are 
responsible for its existence. Ballantyne makes a special variety of the type 
which is due to obstruction within the urethra and which causes extreme thick- 
ening of the bladder walls and the ureters. In some of these hypertrophic cases, 
however, no obstruction can be found, so that the existence of a spasmodic 
stenosis must be assumed, and it is this factor which permits us to place the 
affection among true diseases. Hydronephrosis: This condition, the result of 
embryonal malformations, is considered under " Dystocia of Fetal Origin " 
(Part IX). Cystic Degeneration of the Kidneys: The nature of this condition is 
obscure. If due to a sclerogenous inflammation of the urinary tubules, it would 
be a disease, otherwise it would have to be placed with fetal neoplasms of em- 
bryonal origin. It is considered under " Dystocia of Fetal Origin." Diseases 
of the Genitals: These organs, representing a persistence of embryonal structure 
during the fetal period, are subject to malformations rather than diseases. A 
congenital prolapse of the uterus is known to occur, almost always in associa- 
tion with spina bifida, and is described in great detail by Ballantyne. A red 
mass is seen to project from the vulva at birth. 



ANTENATAL DISEASES OF THE FETUS. 



297 



9. Antenatal Cutaneous Diseases. — There may be a failure of development 
in any one or all of the specialized structures of the skin, evident at birth or in 
the fetus, as happens in the case of other organs. When the lack is total (e. g., 
atrichia), it is apt to be accompanied by other deformities. More or less local- 
ized aberrant growth is shown in the formation of nasvi of various sorts — vascular, 
pilary, pigmented, papillomatous, verrucous. Aside from these tumors, the 
commonest misdirection of the great embryonic cellular activity is in increase of 
the surface layers of the epidermis, the stratum corneum particularly, which is 
called ichthyosis. There are two varieties, one which is congenital and one 
which develops after a few years have passed. 

(1) Ichthyosis Congenita (Hyperkeratosis Congenitalis, Harlequin Fetus, 
Universal Congenital Kera- 
toma) (Fig. 446). — The chil- 
dren are usually premature and 
immature. They rarely sur- 
vive more than a few days, 
but Sherwell has seen one 
child live as long as five 
months. The skin is covered 
with polygonal horny plates, 
one-sixteenth of an inch or less 
in thickness, closely adherent 
and separated from each other 
by deep furrows, which in the 
neighborhood of the orifices 
may extend into the cutis 
and consequently bleed. The 
whole body is encased in a 
horny armor which, failing to 
keep pace with the growth of 
subcutaneous tissues, bursts 
always at right angles to the 
direction of the thrust from 
below. About the joints the 
cracks usually take a circular 
direction. As expansion is pre- 
vented, the mouth cannot be 
closed, preventing taking of 
nourishment, the ears are flat- 
tened against the head, and the 
lids are ectropic. As a conse- 
quence of the latter, conjunc- 
tivitis and ulceration develop. The genital region is generally free. The skin 
is dry, grayish-yellow, and easily pinched up, like that of old people. Sweating 
is generally free, but anhidrosis was complete in Caspary's case. The hair folli- 
cles, sebaceous glands, and panniculus adiposus are atrophic or absent. If the 
child lives for any length of time, a failure of development of the musculature 
of the limbs becomes evident and the feet and hands are distorted, the latter 
looking like claws. Etiology: It does not seem possible to trace any family 
predisposition in these cases. The only reasonable theory of origin is that sug 
gested by Bowen, who claims that the hyperkeratosis is due to a persistence of 
the epitrichial layer of the fetal skin. This layer is composed of ballooned 




Fig. 446. — Fetal Ichthyosis. — (Kyber's case.) 



298 PATHOLOGICAL PREGNANCY. 

cells which disappear ordinarily after birth. In this instance they give way 
in iitero to the normal keratinized cells of extrauterine life. It may follow also 
that the earlier the intrauterine change, the severer is the process at birth and 
the less likely is the child to be viable. Hi 'sto 'pathology : The condition is due 
entirely to hyperkeratosis, an increase in the completely keratinized cells of 
the horny layer. Pressure also causes an atrophy, or perhaps a failure of 
development, of the subcutaneous fat and the pilosebaceous follicles. The 
sweat glands, on the contrary, are numerous and greatly developed, a phe- 
nomenon which may be connected with their office of supplying fat to the 
epidermis. Their ducts are readily traceable to the surface. Muscle and bone 
atrophy are later developments. Diagnosis: The picture is so characteristic 
and unique that there can be no difficulty in arriving at a conclusion. Treat- 
ment is usually not called for, as the child is either dead at birth or succumbs 
soon after. In the rare event of survival, effort should be directed to softening 
the epidermis by baths, soap, and inunction with oil or grease containing a 
small percentage of sulphur, resorcin, or naphthol. If the condition can be so 
relieved as to permit nursing, the child may live, since the internal organs 
functionate normally. Prognosis, of course, is unfavorable. 

(2) Keratolysis Exfoliativa is a congenital affection described by 
Sangster. In it a condition obtains in which the loosened horny stratum 
comes away in large thin flakes, and leaves a reddened prickle-cell layer, 
indicating a lack of the normal adhesive quality between the epidermic 
cells. The affection is excessively rare, and is not very remotely related to 
ichthyosis, at least so far as the histology goes. Rasch has reported three cases 
occurring in one family, two of which were fatal by intercurrent disease early in 
life, the other subject reaching the age of thirty-two at the time of examination. 
In all the cases the condition dated from birth. In Sangster's case the desqua- 
mation was periodical, unaccompanied by much redness. The general health 
was not affected to any appreciable extent. Treatment is necessarily palliative. 
Regular bathing, followed by inunction with oil or lanolin, is the best that can 
be done in such a condition, but, persisted in from day to day, gives good results. 

(3) General Cystic Elephantiasis. — This affection is thought to possess 
a close relationship with general fetal dropsy, although it may also be allied 
to localized forms of elephantiasis. It must not be confounded with the 
solid elephantiasic condition of the skin and subcutaneous tissues. In place of 
a general uniform anasarca, the subcutaneous tissue is occupied by cysts of 
various sizes. AYhile universal, like general anasarca, it is likely to be more 
marked in particular localities. Ballantyne regards it as either inflammatory 
in nature, or as due to lymphostasis. The affection was known long before its 
present designation was applied to it. The first modern pathologists regarded 
it as a form of fibroma molluscum, and its actual nature appears to have been 
first recognized by Steinwirker in 1872. A number of authors prefer to call it 
gelatinous anasarca. Frequency: Ballantyne, who has carefully gone over the 
literature of the subject, has collected notes cf some eighteen cases. Naturally, 
this small number bears no necessary relationship to the actual frequency of the 
affection, but it is safe to state that it is very rare. Clinical History: Of the 
eighteen recorded cases, only one occurred at term; abortion and prematurity 
clearly predominate in gestation with this disease. As in the case of general 
dropsy, survival after birth is the exception. Of two children born alive, one 
lived half an hour, the other twenty months. The collected cases include a case 
each of twins and triplets. Of the twins, the first one was normal, while of 
the triplets, the second alone was affected by the disease in question. Pathology: 



ANTENATAL DISEASES OF THE FETUS. 



299 



The uncouth appearance presented by some of these fetuses, with preponderance 
of swelling in certain localities, especially of the head and face, was very sugges- 
tive of monstrosity, and has doubtless served in the past as a supposed support 
to the theory of maternal impressions (Fig. 447). A few of the recorded cases 
were clearly cases of omphalositic monsters (Fig. 394). Unlike general dropsy, 
cystic elephantiasis appears to present few or no anomalies of cord and placenta. 
Etiology and Nature: We know that there must be some distant relationship 
between this disease and multiple pregnancy. The affection is probably con- 
nected in some way with the lymphatic apparatus. This theory brings it in 
relation with other forms of elephantiasis congenita. Ballantyne is inclined to 
regard cedema as the first stage of elephantiasis, which is followed, in theory at 
least, by structural changes. Diag- 
nosis: Cystic elephantiasis is not 
recognizable during pregnancy, nor, 
in the recorded material, was the dis- 
ease recognized during labor. After 
labor the diagnosis should be readily 
made, although simple dropsy may 
at times closely resemble it. Prog- 
nosis: The mother's welfare is not 
especially endangered, aside from the 
fact that labor itself, being usually 
premature, may add to the ordinary 
hazard. The fetus has no chance 
of survival, despite the exceptional 
child which lived to the age of 
twenty months. Treatment: There 
is no treatment, in the ordinary sense 
of the word, to employ. 

10. Fetal Bone Diseases. — The 
skeleton diseases of the fetus repre- 
sent but a single basic condition: 
viz., irregular or imperfect ossification 
(Fig. 448). In virtue of the great 
mass of names which have accumu- 
lated in the literature of this condi- 
tion, Ballantyne proposes to abolish 
them all and describe a single affec- 
tion which occurs in four types. 
Thus, Type A consists essentially of 

a softening of the bones, betrayed by the presence of craniotabes and curvature 
of the long bones. Type A is more similar to extrauterine rickets than any other 
fetal bone disease. Type B exhibits a great fragility of osseous tissue, as well as 
curvature and shortening of the long bones. The latter fracture from simple 
manipulations. While these two types have more or less resemblance, Type C 
is radically different, being characterized by extreme overgrowth of the epi- 
physes of the long bones. The diaphyses appear correspondingly short. This 
hyperplasia of the cartilaginous epiphyses of fetal life must be related in some 
manner to the enlargement of these portions of the skeleton in extrauterine 
rickets. This type of fetal bone diseases has been known as chondrodystrophia 
fcetalis. Type D is in some respects the converse of the preceding, and 
is usually known as achondroplasia. It is seated chiefly in the limbs and 




Fig. 



447 



-General Cystic Elephantiasis. 
— {Ballantyne.) 



300 



PATHOLOGICAL PREGNANCY. 



trunk, the head being approximately normal. The disorder is essentially de- 
fective endochondral ossification. The diaphyses of the long bones are reduced 
in length from a half to a third, the epiphyses being normal. This is the most 
striking feature of the disease. The individual has very short limbs, the brevity 
of the lower extremities conferring upon him a dwarfish stature. The achon- 
droplasic dwarf differs from the phocomelus monster largely because in the 
latter the affection dates from the embryonal period, while in the former it 
develops in the course of fetal life. 

ii. Fetal Traumatisms. — Injuries occurring during fetal life must be dis- 
tinguished from traumatisms of intra-partum origin, on the one hand, and certain 
accidents which probably date from the embryonal period, on the other. This 






Fig. 448. — Four Skulls showing Lack of Development of the Parietal Bones (" False 
fontanelles ") and congenital flssures of the parietal and occipital bones 
("False Sutures"). — (Author's collection.) 



is by no means a simple matter. Fetal injuries become apparent only at birth, 
and often only through its consequences. If an injury at birth is recent, 
unrepaired, it is hard to demonstrate that it was not received during labor; 
while, on the other hand, if we find at birth a malformation which suggests a 
traumatic origin, there is often at least a possibility that the injury was received 
during the first six weeks of life, which makes the condition a technical mon- 
strosity. Fetal traumatisms may be divided into wounds of soft parts, fractures, 
dislocations, and amputations. 

Wounds. — Scars and circular defects of the skin have been found at times. 
When the former occur over what appear to be badly united fractures of the 
long bones, it is possible that the osseous injury was complicated at the time by 



ANTENATAL DISEASES OF THE FETUS. 301 

a cutaneous wound. The circular defects which are usually encountered on the 
scalp are due, it is thought, to the tearing away by amniotic adhesions of portions 
of the integument (see Congenital Defects of the Skin, Section VI). 

Fractures. — Clinically we understand by this condition various malforma- 
tions which indicate more or less imperfect bony union of a past fracture. Thus, 
observers have noted imitations of all the terminations of fractures in extra- 
uterine life, such as nodular swellings from excess of callus, angular union, false 
joint, etc. In some cases scars of the soft parts over the fractures appeared to 
indicate that the latter had been complicated by a cutaneous wound. As to 
causes of fetal bone fractures, it is difficult to conceive of their occurrence save 
in brittle bones (see Fetal Bone Diseases, page 299). We know that fractures 
occur intra partum under these circumstances (see Fetal Birth Traumatisms, 
Part IX). It is generally admitted that these results of fetal injuries are very 
commonly associated with true malformations, in which case they must be re- 
garded as received during the embryonal period. When it seems clear that the 
injury occurred during advanced fetal life, we must explain it by a peculiar 
combination of causes, such as brittleness of bone, scanty amniotic fluid, and 
excessively strong fetal movements or external violence. 

Dislocations. — What has been said of the nature of fetal fractures will hold 
good for dislocations. Thus, if recent, they suggest an intra-partum origin. If 
evidently due, as in some congenital dislocations of the hip, to defective develop- 
ment of structures forming the joint, the possibility of a teratological origin must 
be borne in mind. This conception of dislocations leaves little to be said of their 
occurrence during fetal life proper. The joint most frequently involved is the 
hip, while the shoulder is sometimes affected. These affections are probably 
considered to best advantage under the head of congenital malformations and 
birth traumatisms. (Part III, Section VI, and Part IX.) 

Amputations. — In the condition known as spontaneous intrauterine or con- 
genital amputation the defect must be of a character to show that a limb once 
existed, or, in other words, an amputation stump must be present. Most authori- 
ties state that the amputated limb, more or less macerated, etc., may be found 
in the amniotic fluid and be expelled with the fetus. The amputation may 
affect any portion of the extremities, from a single finger to an entire limb. The 
occasional presence of what appear to be rudimentary digits upon the end of the 
stump serves to throw added doubt upon the actual nature of these amputa- 
tions. Until recently these injuries were thought to be due to constriction by 
amniotic bands, this explanation being found in most text-books on obstetrics. 
Dermatologists sought to do away with a traumatic element, and regard the 
amputation as having been caused by a sort of sclerodermatous constriction of 
the skin itself. Ballantyne is in favor of doing away with all our present 
views, believing that the mutilation takes place in the embryonal period. 

12. Fetal Neoplasms. — Affections of this class are embryonal in origin, and 
hence to be ranked with anomalies and monstrosities. The fetal tissues may be 
the seat of cysts, fibromata, chondromata, lymphangiomata, exostoses, rhabdo- 
myomata, sarcomata, etc. 

13. General Fetal (Edema. — Anasarca. — Definition: A total dropsical 
condition of the fetus, including complete anasarca and effusion into all the 
serous sacs, the placenta being often oedematous (Figs. 449 and 450). Frequency: 
This affection is extremely rare. Ballantyne could find but 60 cases recorded in 
literature. This number, however, does not include cases of dropsical double 
monsters.' There is sufficient evidence in some cases to connect the fetal 
cedema with developmental anomalies of the fetal circulation, or perhaps with 



302 



PATHOLOGICAL PREGNANCY. 



certain visceral inflammations in the fetus. Diagnosis: The behavior of the 
fetus during gestation presents no peculiarities. Diagnosis during labor is like- 
wise difficult. Anasarcous tissue could readily be confounded with a caput 
succedaneum, or oedema might cause a head to be mistaken for a breech. Should 
a hand or foot present, diagnosis might be possible. Dystocia after birth of the 
head might suggest dropsy of the trunk, but delay at this period of labor might 
be due to many other causes, which would have to be excluded in diagnosis. A 
special friability of the tissues in fetal oedema has more than once made it possible 
to recognize this disease before birth, in the case of manual or instrumental 





Fig. 449. — General (Edema of the 
Fetus. — (Ballantyne.) 



Fig. 450. — General Fetal Obesity and 
(Edema . — (Ballantyne.) 



delivery. Diagnosis after labor is readily made, except in cases of macerated 
fetus and of hydrops sanguinolentus. Maceration of dropsical fetuses is not 
readily distinguished from maceration under other circumstances. Hydrops 
sanguinolentus is a term employed to distinguish the condition usually found in 
a dead-born syphilitic infant, and its consideration belongs under hereditary 
syphilis. Ascites, from its localization, is not difficult to separate from general 
fetal oedema. Congenital cystic elephantiasis is often accompanied by anasarca 
and serous effusions, but diagnosis should not be difficult. Prognosis: The 
mother does not appear to suffer as the result of bearing a dropsical child, while 
the fetus has never vet survived the disease. Treatment: There is no evidence 



ANTENATAL DISEASES OF THE FETUS. 



303 



that treatment of the mother has ever had any salutary influence on the wel- 
fare of the dropsical fetus. • 

General Fetal (Edema in Twin Monstrosities. — Clinical History: There 
are, according to Ballantyne, no cases on record in which both twin fetuses, 
whether normal or monstrous, were afflicted with general dropsy; while but two 
cases are known to have existed in which one of the normal twins has thus suf- 
fered (Fig. 451). On the other hand, in case of separate twins having a single 
cord, the omphalosite or allantoid parasite (i. e., the undeveloped twin, which is 
nourished only from the umbilical cord of its normal fellow, and which consti- 
tutes one of the least developed types of monster) is very frequently the seat of 
general oedema. It is a singular 
fact in teratology that, of all 
the numerous morphological 
varieties of omphalosites, that 
known as paracephalus dipus 
cardiacus is the only one which 
is recorded by title as hav- 
ing been affected with general 
oedema. Diagnosis: This is im- 
possible before delivery. After 
labor it should be easy, the 
omphalositic twin assuming the 
most grotesque shapes imagin- 
able, owing to a high degree of 
oedema of the misshapen organ- 
ism. Prognosis and Treat- 
ment: Prognosis can be spoken 
of only in connection with the 
healthy twin. It is good, for 
the sound individual does not 
suffer through its monstrous 
fellow. Any idea of applying 
treatment is, of course, foreign 
to the situation. 

14. Maternal Traumatisms. 
— The fetus may be seriously 
or fatally injured by external 
violence. This has already been 
noted in the section on injuries FlG 
of the fetus due to external vio- 
lence (page 300). 

15. Maternal Uterine Disease Affecting the Fetus. — Chronic metritis and 
endometritis have been noted as causes of fetal death. Hirst reports two cases 
in which non-development of the uterus was apparently the cause of repeated 
premature deliveries. Prolapse of the gravid uterus may exist. This is not 
often primary in pregnancy, and if the organ does not rise in the pelvis it will, 
especially if the pelvis is small, probably become jammed in by the bony parietes 
and abortion would probably occur. Anteversion of the pregnant uterus is not 
often attended with serious symptoms, but retrodisplacement of the gravid 
uterus is very productive of abortions. The influential causes are metritis and 
endometritis, hyperemia, and hemorrhage into the decidua which result from the 
venous stasis caused by the retro-displacement. 




45 1 -- 



-General (Edema in a Twin Fetus. - 
{Ballantyne.) 



304 PATHOLOGICAL PREGNANCY. 

16. Fever in the Mother Affecting the Fetus. — This is a common cause of 
abortion and prematufe delivery, especially when fever is suddenly developed. 
Many experiments have been made on animals in order to arrive at the definite 
effects that high temperature of maternal origin produces in the fetus. Views 
on the subject have changed to a great degree accordingly. It has been shown 
in the guinea-pig, for example, that the fetus can endure a much higher tempera- 
ture than had formerly been supposed. In one case, the animal after attaining 
a temperature of 111.2 F. (44 C), lived nine minutes.* Danger to the fetus 
must be feared only when the maternal temperature rises suddenly or reaches a 
point over 105 F. (40.5 C). In the latter case energetic antipyretic measures 
would be indicated. In case of maternal death, post-mortem Caesarean section 
or accouchement force would be useless if the patient's temperature had reached 
109 F. (43 C), or if it had risen with great rapidity. t 

17. Death of the Mother Affecting the Fetus. — The effect of the maternal 
death upon the fetus in utero is considered in the section on post-mortem delivery 
(Part V). 



VIII. DEATH OF THE FETUS. 

1. Maceration. 2. Mummification. 3. Absorption. 4. Putrefaction. 5. Saponification. 

6. Calcification. 

Etiology. — Successive pregnancies in the same mother may result in still- 
births, or in the birth of children who live but a short time. Syphilis in one of 
the parents is thus suggested, and, according to Ruge, it occurs in 83 per cent, 
of the cases. Other conditions, however, may produce a like result. Apoplexy of 
the placenta, membranes, or ovum itself, resulting from an inflammation of these 
tissues, is a frequent cause of fetal death. Systemic poisoning of the mother with 
lead, mercury, or tobacco may result fatally to the fetus. Not only maternal 
influences are to be considered in fetal death, but paternal conditions as well, 
such as old age, extreme youth, alcoholism, chronic disease, etc. Sometimes no 
apparent cause can be discovered, and the mother seems to abort simply from 
habit, and at about the same period in her pregnancies. The essential cause of 
this catastrophe may be in the fetus itself, from diseases, injuries, or deformities. 
The effect of the death of the fetus on the mother may be really nil unless the 
germs of putrefaction in some way reach the body. 

Diagnosis of Fetal Death. — (1 ) The uterus ceases to grow or diminishes in size. 
(■2) Subjective symptoms of pregnancy gradually disappear. (3) The milk 
secretion appears. (4) The fetal heart -sounds and movements disappear. (5) 
There are loss of resiliency and crepitation of the fetal skull. This latter occurs 
only when the fetus has been dead for some time, and the head has become 
quite macerated, so that the bones are loosely joined together. (6) Peptonuria 
and disturbance of renal function occur. (7) Diminution of cervical temperature 
is noted. (8) There is absence of pulsation in the umbilical cord, or in the fetal 
precordium, which may be learned by introducing the hand within the uterus. (9) 
Stoltz's sign is not positive, but is supposed by Stoltz to consist in a slight mur- 
mur or rustle, which is caused by decomposition of the amniotic fluid. (10) 
Certain changes in the health or the condition of the mother have been supposed 
to point to the existence within her uterus of a dead fetus, such as depression of 
spirits, pallor of the face, a feeling of weight in the lower part of the abdomen; 

* Preyer: " Physiologie des Embryo," Leipzig, 18S4. 



DEATH OF THE FETUS. 



305 



but these signs are uncertain. The health of the mother is not affected, so long 
as the membranes remain unruptured. 

Changes in the Fetal Structures. — The kind of change that will take place in the 
fetus depends on the time of its death, the 
length of time from that event until expul- 
sion, and whether or not there will be access 
of air to the amniotic sac. (i) Maceration 
(Fig. 452) : This is the most common change 
in the fetus after death. The skin loses its 
physiological activity, and, as a result, the 
vernix caseosa is no longer secreted for the 
protection of the fetus, and the liquor 
amnii produces maceration. A fetus in 
this condition is known as a foetus sangui- 
nolentus. The surface is likened in appear- 
ance to a washerwoman's hand, wrinkled 
and softened. Here and there the epithe- 
lium has desquamated, leaving glistening 
red spots. All of the tissues, even to the 
internal organs, are, as it were, water-logged. 
The cord lacks the normal spiral aspect, be- 
ing round, soft, and smooth. The amniotic 
fluid, as noted under that heading, is much 
discolored from the absorption of the blood 
coloring-matter and the products of de- 
composition. It may be reddish, greenish, 
or brownish, and it may possess an offen- 
sive odor. (2) Mummification (Figs. 453, 
454, 455): This change sometimes occurs 
after a missed labor. It may be regarded 
as typical in a dead fetus which has attained the age of several months, but can 
occur only when the membranes have remained unruptured. If the fetus has 

for some time been subjected to 
pressure, as in the case of twins 
when the live embryo by its 
growth gradually compresses the 
dead one, the latter will finally 
become very flat, and is then 
known as fcetus papyraceus (Fig. 
455). This process of mummi- 
fication has been rightly named, 
for such a fetus is dry and 
shriveled in appearance. The 
color is grayish-yellow, and the 
consistency is leathery. The 
amniotic fluid, which is lacking, 
has either been absorbed by the 
chorion or drained off, conse- 
quently the fetal appendages are 
likewise dried and tough, and 
show some fatty degeneration. 
This condition is frequently 




Fig. 



452. 



-Macerated and Syphilitic 
Fetus. — (Lepage.) 




Fig. 453. — Mummified Fetus and Necrotic De- 
cidua. The fetus died at the third month, but 
the entire ovum was retained for seven months 
more. The decidua and chorion are filled with 
coagulated hematomata. The fetus measured 3 -J 
inches (8 cm.) , was much deformed, and the left 
foot was adherent to the right leg. — (Schaeffer.) 
20 



306 



PATHOLOGICAL PREGNANCY. 



caused by the twisting of the cord around the neck of the fetus. (3) Absorption : 
Total absorption can occur only in the first ten or twelve weeks of pregnancy. 
It has occurred in intrauterine pregnancy, and is a favor- 
able termination in extrauterine pregnancy. The first 
step in this process is maceration of the fetus, followed by 
a complete absorption. The striking characteristic is 
the thick and mucilaginous condition of the liquor amnii. 
(4) Putrefaction : So long as the membranes remain 
intact, putrefaction is impossible. Physometra and 
tympanites uteri may subsequently occur as the result 
of this transformation. In this process the soft parts 
are disintegrated, leaving the bones to be disposed of, 
either by ulcerating their way through the overlying 
structures, or by surgical removal. It is not uncommon 
to find suppuration coincident with putrefaction. (5) 
Saponification : Saponification and adipoceration are 
parts of same chemical change, by which the fetus be- 
comes fatty or soap}', through the deposit within its 
tissues of margarates of calcium, potassium, cholesterin, 
and sodium. After this transformation it has a charac- 
(6) Calcification (Fig. 456): This change may occur as an 
intrauterine or extrauterine termination of 
pregnane}', when a lithopedion is formed. 
The process consists of the deposition of lime 
salts in the fetal tissues, after which it is also 
known as a " stone child." There are recorded 
cases in which this condition has been shown 
to exist for years, the petrified fetus being re- 
tained in utero. 




Fig. 454. — Mummifica 
tion of the fetus, 

— (Galabin.) 

teristic greasy feel. 





Fig. 455. — Fcetus Papyraceus. 

— (Author's case.) 



Fig. 4s6. — Lithopedion ("Stone Fetus"). 

(Ahlfeld.) 



DISEASES OF THE GENITAL ORGANS. 



307 



IX. DISEASES OF THE GENITAL ORGANS. 

I. Anteflexion and Anteversion. 2. Retroflexion, Retroversion, and Incarceration. 3. Latero- 
flexion and Later over sion. 4. Prolapse of the Pregnant Uterus. 5. Torsion. 6. Hernial 
Protrusion of the Pregnant Uterus. 7. Periuterine Inflammation and Adhesion. 8. Rheu- 
matism of the Uterine Muscle, p. Metritis. 10. New Growths in the Uterus. 11. Spon- 
taneous Rupture. 12. Malformations. 13. Leucorrhea. 14. Cystic Vaginitis. 75. Specific 
Vaginitis. 16. Prolapse of the Vagina, ij. Pruritus Vulva. 18. Varicosities of Vagina 
and Vulva, iq. Vegetations. 20. CEdema of the Vulva. 21. Eczema of the Nipple. 22. 
Mammary Abscess. 23. Hemorrhage from the Genitals during Pregnancy. 

i. Anteflexion and Anteversion (Fig. 153). — In the later months of pregnancy, 
owing, in multigravidae, to the lax condition of the abdominal walls, or to the sepa- 
ration of the recti, or to the giving way of an old cicatrix, anteflexion and ante- 
version may occur, giving rise to the condition known as pendulous abdomen, 
or " hanging belly." This condition is also a frequent accompaniment of pelvic 
deformities, due to the fact that the uterus cannot descend, as in normal preg- 
nancy. The fundus, under such circumstances, may be lower than the cervix, 



Ant.a6d.traU 

Ant. Per. fat. — 
Parietal Pentonetur 



Vessets of Clitoris 

1/retAra 

Ladiurn, minus — 

Tritfon of Bladder— 

Vagina — 

Perineum, — 

Sphincter am externus 

Jphinder ani internets 




Umbilicus 
Left Com. it. art. 

Left Com.il: rein 
Norn of Uterus 
I ferine port of rt.fidre 
I ferine yes. pouch 
- Uterine vessels 
Dour, 



i 



'ero sacral 
ligament 



Fig. 



457- 



-Enormous Distention of the Bladder, Rectum, and Sigmoid Flexure, 
causing Posterior Displacement of the Uterus. 



the latter being carried upward and backward into the hollow of the sacrum; 
thus labor may be greatly complicated, and the presenting part be directed 
away from the axis of the pelvic outlet. Incarceration of an anteflexed, pregnant 
uterus, although rare, has been known to occur, as the result of an inflammatory 
adhesion, or after the operation of anterior fixation or suspensio uteri. In these 
cases there are usually severe vesical symptoms, and interruption of pregnancy, 
or the uterus goes to term and operative procedures are necessary to deliver the 
fetus from the uterus, which has, so to speak, buckled upon itself. (See Maternal 
Dystocia, Part V.) As a general rule, the uterus replaces itself spontaneously 
by its own growth. In may be bound down by adhesive bands, resulting from 
inflammation, in which case pain and difficult micturition supervene. The organ 
then either forces itself upward into the abdomen or expels its contents. If 
there are no pelvic tumor, no exudate, and no previous anterior displacement to 
account for the pathological position, then its cause will probably be found in a 
contracted pelvis, or in retraction of the utero-sacral ligaments. This condition is 
also accentuated by the intra-abdominal pressure brought to bear on the posterior 
uterine wall. In rare cases traumatism may cause acute anterior displacement. 



308 



PATHOLOGICAL PREGNANCY. 



A few believe in the causal relationship of anterior displacements to the per- 
nicious vomiting of pregnancy, but this I have failed to confirm. This malpo- 
sition often causes sterility, but seldom has any relation with abortion. Symp- 
toms: In extreme cases of this condition, shoulder presentations of the fetus must 
be looked for, and there will be pain in the distended skin, oedema of the lower 
abdomen, vesical and rectal disorders, while locomotion will often be accom- 
plished with great difficulty. Treatment: In the simple and non-adherent cases, 
which occur in the early months of pregnancy, it will usually be sufficient to 
regulate the bowels and to keep the patient in the recumbent posture for the 
greater portion of the time. In case of pendulous abdomen the uterus should be 
replaced and retained by a moderately firm bandage (Figs. 232 and 233). In 
the adherent or incarcerated cases an effort should be made, under etherization,, 
with careful manipulation, to break 
down the bands of adhesion; if this 
fails and no marked symptoms are 




■ ' ■ : 




Fig. 458. — Retroflexion and Prolapse 
of the Pregnant Uterus. Danger of 
sloughing into the posterior vaginal 
wall, the anterior rectal wall, or through 
the perineum. 



Fig. 459. — Incarcerated RetroflexeD' 
Pregnant Uterus, with Greatly Dis- 
tended Bladder. 



present, the case may be allowed to proceed as far toward term as it will. I 
delivered one child by version at term from such an adherent uterus, the result 
of anterior fixation for retroflexion. 

2. Retroversion and Retroflexion (Figs. 457 to 463). — Retroversion is the 
most important of the uterine displacements, on account of the serious re- 
sults which sometimes follow it. It is a cause of sterility, and if conception 
does take place, the malposition generally corrects itself by the end of the third 
or fourth month. At times abortion occurs. In multigravidae retroflexion is one 
of the commonest displacements, but it rarely causes sterility. 

Etiology. — Backward displacements may be caused by previous uterine dis- 
ease; e. g., adhesions between the uterus and posterior wall of the pelvis, or 
relaxation of the round ligaments. It may also be produced by falls or violent. 



DISEASES OF THE GENITAL ORGANS. 



309 



jars; distention of the bladder may be regarded as a predisposing cause. It is 
more likely to occur in cases of flattened pelvis. 

Symptoms. — Vesical irritation from pressure of the cervix upon the bladder, 
constipation and pain in the back from pressure of the fundus, sensations of 
pressure and weight in the pelvis, are the prominent symptoms, which generally 
come on gradually, rarely suddenly. Locomotion is sometimes very difficult; 
there are frequent reflex phenomena, vomiting holding a prominent place. On 
examination, the cervix is found elevated, the body of the uterus is in the cul-de- 
sac of Douglas, the anterior vaginal fornix is empty, and the bladder is displaced 
downward and backward. 

Terminations. — Retroversion usually disappears with the upward growth 
incident to pregnancy, by the end of the third month, by (i) spontaneous reposi- 
tion. When this does not occur, however, and when the fundus remains poste- 
rior, the increase in size of the uterus 
causes an aggravation of all the 
symptoms, and if the upward growth 





Fig. 460. — Sagittal Section of a Re- 
troflexed incarcerated pregnant 
Uterus at Five and a Half Months. 
Necrosis of the Bladder and Death 
Resulted. — (Schwryzer*) 



Fig. 461. — Retroflexion and Firm In- 
carceration of the Uterus in a 
Primigravida. Uterus bicornis was 
present. The bladder and uterus were 
punctured and abortion resulted. — 
(Schatz.t) 



and ascent of the uterus are prevented by the promontory of the sacrum, the 
condition is known as (2) incarceration. (3) Spontaneous abortion or mis- 
carriage is another termination, caused by uterine congestion and interference 
with the growth of the fetus. 

Incarceration (Figs. 459, 460, 461). — By incarceration is meant the reten- 
tion of the uterus below the promontory of the sacrum and in the true pelvis. 
If the retroflexed or retroverted uterus is not replaced, or if spontaneous 
reposition or abortion does not occur, the increasing size of the uterus results 
in its firm impaction in the pelvis. The symptoms are vesical irritation and pain 
in the back ; retention of urine from pressure upon the bladder ; and obstinate 
constipation, or even obstipation, from pressure of the fundus. The genitals 

* "Arch. f. Gyn.," Bd. xli, Taf. viii, Fig. 1. 
t "Arch. f. Gyn.," Bd. i, Taf. viii, Fig. 1. 



310 



PATHOLOGICAL PREGNANCY. 



and thighs may become swollen and ©edematous, and grave symptoms, the re- 
sult of peritonitis, due to rupture of the bladder or to sloughing of the uterus or 
to severe metritis or parametritis, may ensue. Abdominal palpation fails to 
disclose the fundus, while vaginal examination shows that the latter is im- 
prisoned in the cul-de-sac of Douglas. The latter fact may be made plainer by 
examination per rectum. The cervix may be found behind the symphysis, or 
it may be difficult or impossible to reach it. There maybe great distention of 
the bladder, and the perineum may even be distended by the pressure of the 
fundus. 

Diagnosis. — Incarceration, especially in its early stages, may be confounded 
with extrauterine pregnancy. In the latter condition, however, though the 



Xv 




Fig. 462. — Partial Retroflexion. The posterior uterine wall is fixed in the pelvic 
cavity. The anterior wall dilates and the dotted lines show the progressive dilatation 
of the anterior uterine wall. — (Bumm.) 

uterus may be somewhat enlarged, the normal relations of the cervix and fundus 
are still preserved; distention of the bladder does not usually occur, nor is there 
oedema of the vulva, or perineal distention, or severe symptoms of pelvic con- 
gestion. The rupture of the sac in extrauterine pregnancy usually occurs near 
the end of the second month, while incarceration usually develops during the 
fourth month. In cases of incarceration uterine contractions may be recognized 
in the tumor. In doubtful cases examination under anesthesia, with the bladder 
empty, will be necessary. There is often dribbling of urine at the third or fourth 
month. Menorrhagia would differentiate this condition from intrauterine 
polyp. As to the terminations, if the incarceration is not relieved, there may be 
rupture of the posterior vaginal wall and perineum, with extrusion of the uterus; 






DISEASES OF THE GENITAL ORGANS. 



311 



very rarely pregnancy has continued to term, the anterior wall of the uterus 
becoming enormously stretched, and the head of the fetus remaining in the hollow 
of the sacrum. Sloughing of the uterus may occur, with the discharge of its 
contents into the vagina or rectum. 

Prognosis. — In the lesser forms of displacement, occurring early in pregnancy, 
the prognosis is good since spontaneous replacement usually occurs. Even in 
cases of incarceration the prognosis is good if the condition is promptly and 
properly treated. In neglected cases, however, it is very bad, since the patient 
is exposed to many dangers, including rupture of the bladder, sloughing of the 
uterus, septic peritonitis, shock, and exhaustion. 




Fig. 463. — Reduction of an Incarcerated Retroflexed Pregnant Uterus by Means 
of Fundal Pressure, Traction on the Cervix, and the Knee-chest Posture. — 
(Bumm.) 



Treatment. — The bladder and bowels being emptied, in the simpler forms of 
displacement an effort may be made to replace the uterus by pressure with the 
fingers while the patient is in the lithotomy position ; but reduction will be more 
easily effected if the patient is in the knee-chest position. (See Operations, 
Part X.) A repositor may be used if failure attends the attempt with the fingers, 
and pressure should be made in the upward direction and to one side, in order to 
avoid the promontory. The reduction will be more easily accomplished if the 
cervix is at the same time drawn downward by a volsellum forceps (Fig. 463). 
After replacement, the newly acquired position of the uterus should be main- 
tained by a pessary or tampon, large enough to be efficient. If the uterus is 
strongly bound down by adhesions, steady and long-continued pressure should 



312 



PATHOLOGICAL PREGNANCY. 



be kept up, by thoroughly tamponing the posterior cul-de-sac through a Sims 
speculum, with the patient in the knee-chest position, the boro-glyceride tam- 
pons being renewed daily ; if this fails abortion should be induced before incar- 
ceration takes place. I have seen the insertion into the vagina of a rubber bag, 
filled with water and kept in place with a T-bandage, act well in cases not of 
long standing. This gentle, continuous pressure is very efficacious. After re- 
duction, it will be well to apply a large-sized Hodge pessary. When reposition 
is once well effected, there is not much danger of a relapse. 

Treatment after Incarceration Has Occurred. — Strict asepsis should be ob- 
served, and the bowels and bladder emptied. Considerable difficulty may be 
experienced in passing a catheter, owing to the height of the bladder and the 
compression of its lower part ; a prostatic or gum-elastic catheter should be tried. 

By drawing down the cervix by a 
vulsellum forceps, the passage of the 
catheter will be facilitated. If skil- 
ful and careful efforts to pass the 
catheter are not successful, the blad- 
der must be aspirated with rigid 
asepsis, about two inches above the 
symphysis. Efforts at reduction are 
then instituted under anesthesia, and, 
if not successful, the induction of 
abortion will be the last resort. If 
the cervix cannot be reached by 
drawing it down with vulsellum for- 
ceps, it will be necessary to aspirate 
the uterus through the posterior 
vaginal cul-de-sac. The most promi- 
nent part should be selected, and as 
soon as the bulk of the uterus has 
been sufficiently reduced by the dis- 
charge of the liquor amnii, the organ 
should be replaced, the cervix seized, 
the os dilated, and the uterus emptied 
in the usual manner. In rare cases 
the induction of abortion may be 
impossible, and vaginal hysterectomy 
will be necessary, especially if slough- 
ing of the uterus have occurred. 
-These are not very frequent, and are 
usually due to some malformation. A moderate deviation to the right is a 
normal condition, constituting the right lateral obliquity of the pregnant uterus. 
In rare cases the uterus is deviated laterally, owing to a congenital shortening of 
one of the broad ligaments. Again, there may be a defective development of 
one side of the uterus, causing latero-flexion. Excessive lateral deviation some- 
times occurs in cases of pelvic deformity. (See Pelvic Deformity, Part V.) 
The effects of these malpositions are more striking in labor than in pregnancy. 
(See Maternal Dystocia.) 

4. Prolapse of the Pregnant Uterus (Fig. 464). — This is an uncommon oc- 
currence, and in most cases the prolapse antedates the conception. It may, 
however, occur during pregnancy, either as a result of a severe shock or fall, or 
from a lax condition of the pelvic floor, due to an old laceration of the peri- 




Fig. 464. — Total Prolapse of a Retro- 
flexed Pregnant Uterus, Due to Pres- 
sure of a Large Pedunculated Ovar- 
ian Cyst on the Left Side, Completely 
Filling in the True Pelvis, and Reach- 
ing to the Umbilicus. Rectocele and 
Ischuria. — (Schaeffer.) 



3. Latero-version and Latero-flexion. 



DISEASES OF THE GENITAL ORGANS. 



313 



neum. It may be caused by retroversion, and it is almost without excep- 
tion found in multigravidae. There is probably no case on record in which 
pregnancy continued till term in a uterus outside the vagina. In the 
cases reported the condition was probably one of hypertrophic elongation 
of the infravaginal portion of the cervix, the fundus of the uterus being 
in the pelvis. Hypertrophy of the supravaginal or infravaginal portion 
of the cervix simulates procidentia, and if amputation of the hypertro- 
phied cervix is performed during the third month, pregnancy may continue 
without disturbance; in aggravated cases this treatment is indicated. Ter- 
minations: Spontaneous reduction usually takes place, in consequence of the 
upward uterine growth incident to pregnancy; in rare cases incarceration may 
occur, producing pain, pressure symptoms, congestion, and, if not relieved, 
abortion. Diagnosis: It has been confounded with cervical hypertrophy, and 
this mistake should be avoided, 
lest it lead to efforts at reposition, 
which may result in abortion. 

A careful bimanual examination, t \ 

with the recognition of the body of | 

the uterus in its normal posi- 
tion, should prevent this mistake. 
Treatment: The bladder and bowels 
should be watched, and the patient 
should spend much of her time in 
the recumbent position with the 
hips elevated, and standing, walk- 
ing, and lifting should be avoided. 
When the prolapse is considerable, 
the uterus should be replaced and 
kept in position by an air or water 
pessary and a vulvar napkin if re- 
quired. When incarceration has 
occurred, the attempt at replace- 
ment should be made with the 
bowels and bladder empty. As a 
preliminary, the patient should be 
placed upon the back with the hips 
elevated, and the congestion of 

the uterus diminished by scarification. The knee-chest position may be of 
service, and anesthesia will be necessary. If replacement cannot be effected, 
the induction of abortion is indicated. After labor prolonged rest should be 
enjoined, with the hope that involution of the organ may result in cure of the 
prolapse. There is always a possibility that pregnancy, labor, and the puer- 
perium will be followed by the cure of old displacements. 

5. Torsion. — In some cases the slight normal twisting of the uterus on its 
long axis from left to right is much exaggerated, or it may be reversed and the 
uterus twisted to the left. This condition is usually due to adhesions, the 
result of inflammatory processes, and in these an ovary being brought forward, 
may be injured by attempts to express the placenta or by manipulation. I 
have never observed a malpresentation or malposition caused by excessive 
torsion. 

6. Hernial Protrusion of the Pregnant Uterus (Fig. 465). — A uterine pro- 
trusion may complicate inguinal, umbilical, or ventral hernia, and when 




Fig. 465. — Labial Hernia of the Pregnant 
Horn of a Uterus Bicornis. C 1 , C 2 , Cor- 
nua uteri; 5, septum. — (Winckel-Eisenhart.) 



314 



PATHOLOGICAL PREGNANCY. 



it occurs in ventral hernia it is usually due to separation of the recti. 
It is sometimes seen, however, on the side of the abdomen, and may 
be due to congenital defects or to an operation cicatrix. Cases of inguinal 
protrusion sometimes occur, in cases of pregnancy, in one horn of a 
bicornate uterus. The protrusion of the pregnant uterus in femoral hernia 
is denied by some writers, but its existence has been asserted by others; e. g., 
Spiegelberg. Sometimes adhesions between the uterus and intestine cause the 
former to be drawn into the hernial sac. There may be hernia of the ovary, 
followed by hernia of the uterus. The symptoms in case of the ventral variety 
are not important, and they are easily mitigated. Not so in the inguinal 

variety, for then incarcera- 
tion and strangulation rapidly 
develop. The prognosis is 
good in the ventral form, but 
grave in the inguinal. The 
diagnosis of a ventral hernia 
will be readily appreciated, 
and an inguinal or a femoral 
hernia will present the symp- 
toms of hernia, with the ab- 
sence of the uterus from its 
normal position, and devia- 
tion of the vagina toward the 
side on which the hernia is 
situated. Treatment: In the 
case of a ventral or umbilical 
hernia the treatment consists 
i ; ^t1 K5P^' vS f JB in reduction and an abdomi- 

nal supporter; in the other 
varieties reduction should be 
effected if possible, and main- 
tained by a truss, by the re- 
TftSH^g "^N^ Ik ? /^?^5r^ cumbent position, and by the 

avoidance of standing, walk- 
ing, and heavy lifting. In 
advanced cases reduction may 
not be possible, even with 
herniotomy, and the induc- 
tion of abortion or hysterec- 
tomy may be necessary as a 
last resort. 

7. Peri-uterine Inflamma- 
tion and Adhesion. — These affections are often alleviated by appropriate treat- 
ment, which should be employed during the intervals between pregnancies 
(Fig. 466). 

8. Rheumatism of the Uterine Muscle. — This is a rare condition. There is 
pain of a neuralgic or a myalgic character, much aggravated by the intermittent 
uterine contractions which normally occur during pregnancy. It is observed in 
patients of the rheumatic diathesis, but may be due to exposure to cold and 
perhaps to violent coughing or straining efforts. Treatment consists in anodyne 
local applications, with anodynes and salicylates internally. 

9. Metritis. — When this occurs it is usually an aggravation of a previously 




Fig. 466. — Periuterine Inflammation and Adhe- 
sion; Tubal Pregnancy; Rupture of the Sac; 
Internal Hemorrhage; Numerous Cord-like 
Adhesions between the Uterus, Left Tube, 
and Intestines. — (Hofmann.) 



DISEASES OF THE GENITAL ORGANS. 315 

existing condition, and thus the symptoms of the pre-existing disease are all inten- 
sified by the physiological hypertrophy of pregnancy. It is one of the causes of 
the pernicious vomiting of pregnancy. Severe pain and the feeling of weight and 
pressure or ' ' bearing-down feelings ' ' in the pelvis are common ; abortion often 
results. Treatment: Boro-glyceride tampons may be used, but if long con- 
tinued are, of course, likely to induce abortion; anodynes are indicated; ex- 
treme danger for the mother, especially from vomiting, may require the induc- 
tion of abortion. 

10. New Growths. — Pregnancy may be complicated by the presence of various 
neoplasms of the uterus, especially fibroid or fibro-cystic tumors. These do little 
harm during pregnancy, as a rule, but symptoms of pelvic congestion are marked, 
often with pain, and their growth is rapid by reason of the increased vascularity 
of pregnancy. In rare cases operative interference may be necessary, on account 
of hemorrhage or excessive distention. As a complication in labor, the situation 
above or below the pelvic outlet, and the mobility of the tumor, will be important 
factors. Malignant growths have been mentioned in connection with deciduoma 
malignum; cancer of the cervix has frequently been mistaken for placenta 
praevia; cystic tumors of the ovary grow very rapidly during pregnancy. New 
growths are far more important as a complication of labor than of pregnancy. 
(See Part V.) The most frequent form is the fibroid, which grows rapidly from 
the increased supply of blood to the genitalia. The cervix is often the seat of 
small polypoid growths which are the source of severe hemorrhage. Operations 
for the removal of new growths do not necessarily interfere with pregnancy. 
(See Operations on Pregnant Women, Part X.) 

ii. Spontaneous Rupture of the Uterus. — This is a rare complication, when 
occurring in pregnancy independent of direct traumatism. It may occur from 
excessive distention; from multiple pregnancy; from hydramnios in a uterine 
wall already weakened by previous prolonged uterine disease, as endometritis 
and metritis, malignant disease, a previous hysterectomy, as Csesarean section, 
or myomectomy for fibroids. It has occurred in the interstitial variety of 
ectopic gestation, and I have seen a case of partial spontaneous rupture, follow- 
ing missed labor, in a case of pregnancy in one side of a uterus septus. The 
symptoms are the same as those of rupture during labor; e. g., concealed hem- 
orrhage and shock. The prognosis could hardly be worse, and the treatment is 
the same as for a ruptured ectopic sac; hysterectomy probably gives the best 
prognosis, although suture of the wound may be employed. 

12. Malformations of the Genital Organs. — (i) Uterus. — These are caused, 
for the most part, by the preservation, to a greater or less extent, of the septa 
between the ducts of Miiller. The student will remember that from the upper 
portions of these ducts, as they converge, are formed the Fallopian tubes, and 
that by their juxtaposition and the absorption of their inner walls the uterus 
and vagina are formed (Fig. 471). If the absorption of the inner walls of the 
tubes does not take place, the uterus and vagina are divided into two lateral 
halves. Should a partial union take place, a corresponding degree of malforma- 
tion results. The organ resulting from this faulty development may present 
the appearance of one body separated into two parts by a partition, indicating 
that the two Mullerian ducts have become joined, but that the partition between 
them has persisted, its absorption not taking place. Or there may be two more or 
less separate bodies, owing to the non-union of the ducts. There are many degrees 
of these deformities, each having its own designation, and the arbitrary limits 
which have been assigned them are numerous. However, the most convenient 
nomenclature would seem to be as follows : the uterus which retains its original 



316 PATHOLOGICAL PREGNANCY. 

partition is known as uterus septus duplex. The partition may exist in approxi- 
mately five degrees. The first and slightest degree results in the uterus incudi- 
formis (Fig. 140) (anvil-shaped uterus), the organ being flattened from above 
downward, and its transverse diameter being longer than the longitudinal. 
Another slight deformity of this variety is the uterus cordiformis (arcuate, 
cordate, or heart-shaped uterus) (Fig. 467); here the original embryonic shape 
of the uterus is suggested by a depression in the median line of the fundus. 
This condition is not often discovered during life, although digital examination 
of the uterine cavity would reveal its existence. In the second degree the 
septum extends the length of the body to the internal os. This form also may 
escape detection, but may be discovered after an abortion or delivery, and it 
may even be destroyed by pregnancy. In the third degree the septum extends 
not only through the uterine body, but also through the cervix. This con- 
dition could easily be recognized by careful cervical examination. In the 
fourth degree the septum runs down into the vagina, but does not completely 
divide it. In the fifth degree the septum divides the vagina completely, causing 
the condition known as vagina septa, or double vagina. It will be readily 
seen that different degrees of persistence of the septum will produce correspond- 
ing kinds of malformation. In this bifid condition, as well as in the double 
uterus, the two sides may be equal or unequal. 

. Double Uterus (Figs. 468, 471). — In this class the organ is more or less com- 
pletely divided into two distinct parts. In the first degree the fundus consists 
of two parts, due to the non-union of the upper parts of Muller's ducts. The 
external surface of the fundus presents a depression or groove, and the resulting 
form is called the uterus bilocularis, or uterus bicornis arcuatus. 

Double Uterus Bicornis, Uterus Duplex Bicornis (Fig. 469). — When the ducts 
fail to unite till they have descended for some distance below the normal point 
of junction, the uterus bicornis, bicornate or bifid uterus, is produced. There are 
two diverging uterine cavities, each communicating with the cervix at one ex- 
tremity, and with a Fallopian tube at the other. The cervix in this form may 
be single or double. When there are two vaginae, one of them may have a blind 
ending above or below. 

Uterus Duplex Separatus cum Vagina Separata. (Fig. 471). — In the uterus 
didelphys, or double uterus, we have a rare condition, in which the ducts do not 
unite at all, and consequently there are two separate uterine cavities and two 
vaginae; each body has its tube and ovary. This is a retrograde form corre- 
sponding to that of the lowest mammalia. The short broad ligament connects 
the diverging bodies. The uterus unicornis results from the faulty development 
of one of Muller's ducts. In a case of this kind one tube and one ovary are gen- 
erally lacking. There are in this form also varying degrees of development. 
There may be a rudimentary horn, or it may be sufficiently developed to allow 
of menstruation, and even of a few months' pregnancy. In cases in which 
the one horn is entirely lacking, there is sometimes discovered the absence of the 
kidney and ureter on the malformed side. The uterus unicornis may possess a 
double cervix, uterus biforis. 

Absent Uterus. — Diagnosis of this extremely rare condition, even under 
narcosis, is never positive. Its existence is nearly always coincident with the 
absence of the entire genital system, pre-eminently the vagina. In searching for 
the uterus, which is not palpable by the ordinary methods, the rectum and 
bladder may be explored at the same time, the former by the index-finger and 
the latter by the catheter. Failure to outline the uterus in this way does not 
offer positive evidence of its absence, since it may be placed in one side of the 



DISEASES OF THE GENITAL ORGANS. 



317 



pelvis, or it may rje in such a rudimentary condition as to defy discovery. Celi- 
otomy or necropsy alone will prove the presence or absence of the organ. 



* 




Fig. 467.— Pregxaxt Uterus Arcuatus, 
Transverse Section. — (Bumm.) 



Fig. 468.— Uterus Biseptus. 



Rudimentary Uterus. — The organ may be represented by a transverse 
bit of connective tissue attached to the bladder, and divided into two parts, to 
each of which is attached a tiny ovary. 
The palpation of these organs is rarely 
possible. In these cases the vagina is 




Fig. 469. — Bicornate or' Bifid Uterus. 



Fig. 470. — Uterus Bipartitus or 
Duplex. 



either absent, or exists in such a stunted condition, with a hymen so very 
small, that the internal genitalia are often thought to be entirely absent. Some- 



318 PATHOLOGICAL PREGNANCY. 

times the vagina is represented by a small cul-de-sac which is continuous with 





Fig. 471. — Uterus Didelphys or Double 
Uterus. C, Uterine cavity; V, vagina. 
— (Dakin.) 



Fig. 472. — Uterus with Two Horns, 
One Developed and the Other Ru- 
dimentary. — {Dakin.) 



the urethra; although so slightly developed, it may become enlarged on 

attempted sexual intercourse. Men- 
struation is rarely present in these 
cases. When it is, it may be so 
painful as to indicate castration. 
Hematometra sometimes occurs. 
Ovulation may take place without 
menstruation. Ordinary bimanual 
palpation, or the method mentioned 





Fig. 473. — Atresia of a Rudimentary 
Horn of a Double Uterus with an 
Accumulation of Menstrual Blood. 



Fig. 474. — Uterus Septus. C, C, Uter- 
ine cavities. — (Dakin.) 




Fig. 475. — Uterus Unicornis. 



Fig. 476. — Uterus with Complete 
Absence of One Horn. C, Uter- 
ine cavity; V, vagina. — (Dakin.) 



under absent uterus, may detect the condition; however, with a well- 



DISEASES OF THE GENITAL ORGANS. 319 

developed vagina and established menstruation it may not be recognized. The 
breasts and pubes are generally well formed. When Muller's ducts are in a very 
rudimentary state, the ovaries are often in a condition of cystic degeneration. 

Fetal and Infantile Uterus; Pubescent Uterus. — Hypoplasia uteri is not an 
atrophic uterus but results from faulty development. The fetal uterus presents 
the characteristics of the organ as found in the fetus — a very small, thin-walled, 
bullet -shaped body, with a cervix several times its length. The vagina is, as a 
rule, short and narrow. The patient generally suffers from extreme chlorosis, 
amenorrhea which defies treatment, and attendant troubles. The infantile 
form presents the normal organ in miniature. The arbor vitae folds do not reach 
to the fundus in this form as they do in the fetal form. The patient is troubled 
with amenorrhea, dysmenorrhea, sterility, and nervous symptoms. Such cases 
should receive systematic treatment, not only general but also local. The 
cervix ought to be dilated and the body subjected to intrauterine faradism, 
as well as medicinal applications. In these cases the vagina, pubes, and mammae 
are generally perfectly formed, although the opposite condition may obtain. 
Menstruation is not often present, nor is sexual desire. 

Imperforate fetal uterus is of very rare occurrence. The body especially lacks 
a cavity. Uterus fetalis bicornis is an organ which presents the fetal character- 
istics in both form and size, and is possessed of the cornua. 

Accessory uteri have been noted. In one case a somewhat smaller uterus, in 
sagittal position, lay in front of the normal organ. The origin of this anomaly is 
not clear. Precocious development of the uterus, with that of the other genitalia, 
is not infrequently observed in small children. Unusual cases have been de- 
scribed in which the mucous membrane of the cervix lies in transverse folds. 
Transverse septa have been found in the cervix. Cases are noted in which 
these septa had to be removed before labor could be completed. Several con- 
genital anomalies of position of the uterus have been noted. The oblique posi- 
tion of the organ, in which the body is bent to one side or the other by the shorten- 
ing of one of the lateral ligaments, also occurs. 

Congenital retroflexion exists in some cases, as well as anteflexion with its 
attendant symptoms, dysmenorrhea, nervous disturbances, etc. 

Congenital prolapsus uteri is rarely met with, and is generally only one of 
several associated stigmata of faulty development. 

Not alone the uterus is subject to malformations, but the adnexa and external 
genitalia as well. One or both tubes may be absent or rudimentary. In the 
former instance the ovaries and uterus are apt to be lacking also. In certain 
cases there are several openings to the tube which may vary in their position. 
The tubes may also present abnormalities in length or calibre. 

(2) Ovaries. — Absent ovaries constitutes also a very rare condition, which 
it is impossible to recognize without direct inspection. These organs may be 
rudimentary, or one alone may be lacking, as in uterus unicornis. The absence 
may be only apparent, as when the o\'ary is attached to one of the other abdom- 
inal organs. Supernumerary, as well as accessory, ovaries have been reported, 
the former being far more rare than the latter. Malposition of the ovaries is not 
very uncommon, and often gives rise to much trouble. In case of the presence 
of a hernia, the prolapsed ovary may slip into the hernial sac, and cause extreme 
pain, while the diagnosis of the condition will be very difficult to make. 

(3) Ligaments. — The uterine ligaments may be defective or absent. This 
condition, especially of the round ligament, is generally associated with faulty 
development of the uterus. 

(4) Vagina. — The vagina may be absent or rudimentary. When absent, the 



320 PATHOLOGICAL PREGNANCY. 

uterus will also generally be absent, or, if present, it will be slightly developed. 
If only a part of the vagina is present, it will usually be the lower part. At 
times the whole vulva may be absent or ill-formed. There are all sorts and de- 
grees of deformities of the vagina, associated with a variety of changes of physio- 
logical function of the internal genital organs. Indications for operative treat- 
ment will depend greatly on the conditions of the whole genital system. Atresia 
may exist at any place in the genital canal, between the vulval opening and the 
internal os. It may be congenital or acquired. Congenital atresia is found, as 
a rule, at the lower end of the vagina. Atresia of the cervix is seldom complete, 
and is the result of cicatricial formation. This may result from laceration in 
labor, or rarely there may be a condition of cervical endometritis, followed by 
agglutination of the lips of the cervix. Complete atresia of the vagina is always 
associated with malformation of the other genitalia. Atresia of the vulva is not 
infrequently seen. The vulva may be absent, and this condition is usually only 
one feature of a general genital deformity. It may also be infantile in its devel- 
opment, as is sometimes seen in feeble women, especially those who have been in 
wretched health before puberty. The nymphse may be absent, very small, or 
hypertrophied. 

(5) Clitoris. — Defects in the clitoris are often of great clinical significance. 
Its absence is a rare condition, but it is not so infrequently hypertrophied, in 
some cases to such an extent that it is difficult or impossible to differentiate the 
sex of the individual. It is sometimes rudimentary or even bifid, as when the 
symphysis is absent, or in exstrophy of the bladder (see Deformities and Mon- 
strosities, page 272). 

(6) Hymen. — The hymen may also present deformities. It may be imper- 
forate, or there may be atresia. The supernumerary hymen that has been re- 
ported is probably, as a rule, a vaginal bridle. The congenital absence of this 
membrane is open to grave doubt, although instances of the anomaly have been 
reported from time to time. In 600 cases of children under sixteen years, exam- 
ined by the writer for evidences of rape, in no instance was the hymen absent 
(see Rape, page 30). 

Malformations of the urethra and bladder are various. The urethra may be 
entirely absent, or only partly defective. Atresia urethra? sometimes exists, but 
generally ends fatally. (See Deformities of the Fetus, page 275.) 

Clinical Significance of Deformities. — Malformation of the uterus may 
affect the course of pregnancy and labor in various ways. In uterus septus duplex 
there are a few cases in which the placenta has been located upon a persisting 
septum, post-partum hemorrhage occurring from deficient retraction. The empty 
half of the uterus may of itself become an obstruction to labor, especially if it 
be hypertrophied and retroverted. During labor it is very apt to sink into the 
sacral hollow, and contract synchronously with the musculature of the pregnant 
part. The pregnant side of the uterus turns toward the median line of the body. 
The clinical significance of this malformed organ is similar to that of the uterus 
duplex bicornis. In uterus arcuatus brow and face presentations are favored 
when the breech is in that segment of the fundus which corresponds to the back 
of the fetus. When pregnancy occurs in the anvil-shaped uterus (uterus in- 
cudiformis) the fetus is forced to assume the transverse position, on account of 
the shape of the uterus, which is flattened, having the transverse at its greatest 
diameter. In the cordate uterus, the cavity being only slightly smaller than 
normal, a two-chambered organ is merely suggested. When the utero-vaginal 
septum is complete, sexual intercourse may take place in either canal. In labor 
the septum itself may offer an obstruction. Laceration of the septum often 



DISEASES OF THE GENITAL ORGANS. 321 

takes place. In uterus duplex bicomis with pregnancy in one horn, the uterine 
obliquity necessarily present may be a cause of faulty presentation, position, and 
attitude. When pregnancy occurs in one horn, confusion in the diagnosis with 
the condition of tubal pregnancy can scarcely be avoided. Menstruation may 
take place from one horn, while pregnancy exists in the other. Different periods 
of pregnancy may exist simultaneously in the two horns ; labor is sometimes 
obstructed by the vesico-rectal ligament which connects the two horns in a 
bicornate uterus. Associated with this malformation are apt to be atony, weak 
labor pains, and faulty involution. In the uterus unicornis with pregnancy in 
that part of the uterus which has become developed, labor is usually normal. 
If, however, pregnancy occurs in the rudimentary horn, the course and termina- 
tion of the case will be similar to that of extrauterine pregnancy (see page 404). 
The rudimentary horn is not suited for the normal course of gestation, and if this 
occurs it results in rupture before the sixth month. The danger of this condition 
is as great as that of tubal pregnancy, from which it cannot be differentiated 
before operation. In the event of atresia of the stunted horn, hematometra will 
develop, the diagnosis of which it may be impossible to determine without opera- 
tion. This may develop into pyometra. When the true nature of this condi- 
tion is known, it is important to open this retention cyst and allow the contents 
to flow slowly out, in order to avoid a sudden change of pressure, which might 
Tesult in the bursting of this thin-walled sac into the abdominal cavity. This 
would put the patient in great danger of infection and septicemia. Especially 
is this caution necessary when hematosalpinx exists as a complication. Should 
the tumor rupture of itself, the tear may be so high up that a part of the sac will 
be left too far out of reach to be properly drained, and this condition will also be 
followed by infection and septicemia. In uterus biforis (one-horned uterus with 
double cervix) there may be considerable trouble during labor. If the septum is 
found, it may be pushed to one side and so kept out of the way, or it may be cut 
between two lines of sutures. Severe hemorrhage has followed its rupture. It 
is plain to see how any of the foregoing deformities may cause trouble of various 
sorts and degrees. There may be trouble with the placenta, as it is not infre- 
quently retained. This may be due to the weak force of expulsion, or to its 
attachment to both cavities of the uterus. This retention may be the cause of 
septicemia. When labor is proceeding, the physician may examine the two open- 
ings alternately, finding now a dilated os, then a contracted os. Or the wrong 
side may be examined, and no internal signs of pregnancy be found. In the case 
of one individual with a double uterus, succeeding pregnancies occurred regu- 
larly on the alternate sides. 

13. Leucorrhea. — One often observes excessive leucorrhea as the result of 
the congestion of pregnancy, and following or accompanying acute or chronic 
inflammation, non-specific in character. Much annoyance is caused by the dis- 
charge itself, and the swelling, heat, and general discomfort. The profuse serous 
discharge becomes later purulent and contains various fungi. In the treatment 
care should be exercised not to excite uterine contractions. The author is 
accustomed to rely mainly upon suppositories of hydrochlorate of hydrastis, 
gr. 1; borate of zinc, gr. ^; extract of belladonna, gr. }; cocoa-butter, or boro- 
glyceride and cocoa-butter, q. s. After careful irrigation of the vagina at bedtime 
with an alum douche, a teaspoonful of alum to the quart of warm water, care being 
taken that there is no obstruction to the return flow, and that the douche bag is 
not more than two feet above the pelvis, one of the above suppositories is inserted 
into the vagina, and a napkin applied for the night. In the morning the alum 
douche is repeated. Other combinations in suppositories are useful. When the 
21 



322 PATHOLOGICAL PREGNANCY. 

uterus is irritable, or the vagina painful or sensitive, suppositories of extract 
of belladonna gr. J, and tannic acid gr. 5-10, are used; and the douche is omitted 
entirely; or a solution of subacetate of lead two teaspoonfuls, and laudanum two 
teaspoonfuls, to the quart of warm water, is used. Care must be taken during 
pregnancy in the employment of any form of tampon with the various prepara- 
tions of boro-glyceride, tannin, zinc, and Hydrastis. 

14. Cystic Vaginitis. — This is an inflammation of the vagina, usually limited 
to the upper two-thirds, and accompanied by the development of small cysts, 
from which, when punctured, air and serum exude; it is attended by a profuse 
frothy discharge, and the symptoms are more acute than those of simple catar- 
rhal vaginitis. The treatment is the same as for leucorrhea. 

15. Specific Vaginitis. — The infection takes place as the result of sexual 
intercourse, but in rare cases it may possibly be caused by the use of infected 
towels, or by other contact with infected surfaces. All the symptoms of simple 
vaginitis are aggravated; there are urethritis and vesical irritation; the discharge 
is profuse and purulent, and contains the gonococcus (diplococcus of Neisser); 
smarting pain accompanying urination is especially prominent ; abscesses of the 
vulvo-vaginal gland sometimes occur, and redness and excoriation of the external 
genitals are common. There is always considerable danger of septic infection 
during labor, and the fetus is likely to develop specific ophthalmia. Treatment: 
The vagina should be irrigated with an antiseptic solution, sublimate solution 
(1 : 4000), or permanganate of potash, and excoriated surfaces cauterized with a 
2 per cent, solution of nitrate of silver; loose tampons of boro-glyceride and 
tannin, or of iodoform and tannic acid, may be used; suppositories of iodoform, 
tannic acid, and cocoa-butter, or hydrastin and boro-glyceride used at bedtime. 
The introduction of the suppository should be preceded and followed by a warm, 
carefully administered lysol or creolin douche (1 per cent.). Since the vaginal 
secretions are alkaline in this affection, Doderlein has suggested the topical appli- 
cation of a 1 per cent, solution of lactic acid to the vaginal walls. Antiseptic 
vaginal douches during labor are advisable, and after delivery the child's eyes 
should be washed with a saturated solution of boric acid, and nitrate of silver be 
instilled into each eye, after the method of Crede' (see Part IX). 

16. Prolapse of the Vagina. — In multigravidae, and occasionally in primi- 
gravidae, — in the former from a previously existing condition, and in both as 
the result of the changes produced by gestation, such as congestion, increased 
pressure, hypertrophy and loosening of the vaginal walls, — a certain amount 
of prolapse of the anterior wall, associated with perhaps some cystocele, is com- 
mon in the later months of pregnancy. Prolapse of the posterior wall with 
cystocele we not infrequently see in multigravidae, and occasionally in primi- 
gravidae, from habitual constipation with overloaded rectum and neglect. I once 
saw a prolapse of the posterior wall with rectocele, in a primigravida, due to 
persistent constipation, in which the rectocele presented in the ostium vaginae; 
I was summoned in the night, the patient mistaking the condition for a possible 
miscarriage. The symptoms are those of vesical and rectal irritation, dysuria, 
frequent micturition, and perhaps aggravation of existing hemorrhoids; the 
physical signs are plain on examination. The treatment consists in careful atten- 
tion to the bowels, the avoidance of tight clothing, the manual reposition of the 
prolapse, and in fitting a proper abdominal support to the patient, to lessen the 
weight of the uterus (Figs. 232 and 233). The abdominal binder described for 
use after the puerperium can be employed to advantage, since it supports the 
lower part of the uterus and the pelvic floor as well (see Part VI). A pneumatic, 
water, or celluloid pessary may possibly be required, held in place by the above, 



DISEASES OF THE GENITAL ORGANS. 



323 



or an ordinary T-bandage. During labor prolapse may prove an obstruction 
(see Part V). 

17. Pruritus Vulvae. — This is always a source of great annoyance, and occa- 
sionally of miscarriage. It is due to irritating discharges or to local conditions ; 



have a reflex origin, 
frequently a neurosis. 



as rectal worms, 
Treatment: The 



I 

1 




j 


^KrWjQQ< 


n 


JF 


1 






^^^^0*m? 


—A 



Fig. 



477. — Varicose Veins of the Vulva. 
— (Case of Dr. William Krusen.) 



it often occurs in diabetes. It may 
and some have asserted that it is 
general health should be attended 
to and the cause should be ascer- 
tained, and treated if possible; the 
urine being always carefully ex- 
amined for sources of irritation, 
as sugar and uric acid. I have 
found, after correcting the irri- 
tating discharges and attending to 
the urine and bowels, that sublimate 
solution (1:1000) is of great value 
in subduing the itching; carbolic 
acid, either in ointment or solution, 
is of value; a drachm of carbolic 
acid to four ounces of ointment of 
rose, or to eight ounces of water 
or oil, may be used. Ointments of 
cocain, ichthyol, resorcin, menthol, 
opium and belladonna, and salicylic 
acid are recommended. 

18. Varicosities (Fig. 477)- — Va- 
ricose veins about the vulva and lower part of the vagina, the result of the 
general pelvic congestion, frequently occur. Constipation should be avoided, 
and in bad cases the vulval region should be supported by a T-bandage, and 
the patient should spend a good deal of time in the recumbent position. The 
compound ointment of gall, and ointments of carbolic acid, cocain, and witch- 
hazel I have found useful. 

19. Vegetations. — These often 
follow gonorrhea, especially when 
the rules of cleanliness are not 
observed ; they are confined to the 
vulva. Cleanliness and the fre- 
quent application of an astringent 
powder, as oxide of zinc, or bis- 
muth and salicylic acid, boro- 
glyceride and tannin, will be suffi- 
cient for treatment ; bad cases may 
be touched with chromic acid, but 
operative treatment should be 
avoided during pregnancy. 

20. (Edema of the Vulva (Fig. 
478). — (Edema here may be uni- 
lateral or bilateral; it may be due to renal insufficiency, in which case it is always 
bilateral, or to mechanical pressure of the enlarging uterus and fetus upon the 
pelvic veins. It may also be due to general anasarca, or to local inflamma- 
tion, as specific vaginitis. When excessive, ulcerative sloughing of the labia 
may occur, and labor be obstructed (see Part V). In the treatment the. cause 




■ 



Fig. 478. — (Edema of the Vulva. 



324 PATHOLOGICAL PREGNANCY. 

is to be sought out and treated: diuretics for the renal insufficiency; an abdomi- 
nal support for pressure; proper treatment for local inflammation. Hot fomen- 
tations and multiple puncture of the tense skin are palliative ; the latter should 
be avoided when possible, for fear of local infection. 

21. Eczema of the Nipple. — This, when occurring during gestation, is apt to 
be a very obstinate affection. For treatment the general health should receive 
attention. Locally the parts affected should be kept clean, frequent washing 
being avoided ; antiseptic, astringent, and desiccating applications should be used ; 
powdered oxide of zinc and salicylic acid make a good application. The nipples 
are to be guarded from irritation and exposure to the air by a protective dress- 
ing, which, however, should not press upon them. The condition is apt to resist 
treatment. I have been most successful with the use of Unna's ointment mull, 
hydrarg. carbolic, (hydrarg., 20 per cent.; carbolic acid, 5 per cent.), cutting a 
piece of the plaster to fit accurately over the affected part, and renewing it daily, 
using only a little sterile vaseline in the removal of the plaster. 

22. Mammary Abscess. — This may occur during pregnancy, but is not 
-common. I had in my service at the New York Maternity a case of double 
mammary abscess at the eighth month of gestation, which was twelve months 
from the birth of the last child. Both breasts were incised, and drainage was 
employed without interrupting the pregnancy. It frequently occurs during 
the puerperium, and is discussed in connection with the pathology of that 
period (see Part VII). 

23. Hemorrhage from the Vagina During Pregnancy. — (See Metrorrhagia of 
Pregnancy.) 



X. THE TOXEMIA OF PREGNANCY. AUTOTOXEMIA OF 
PREGNANCY. HEPATIC INSUFFICIENCY. PREG- 
NANCY LIVER. PRE-ECLAMPTIC STATE. 

r. Toxemia of Pregnancy. 2. Nausea and Vomiting. 3. Icterus. 4. Convulsions and Coma. 

5. Eclampsia. 

i. Toxemia of Pregnancy. — Introduction. — The conception of a special 
toxemia of pregnancy has grown from small and vague beginnings to a well- 
developed and harmonious theory which challenges the attention of every 
medical man. That such a condition exists is no longer a matter of doubt; 
but the extent to which it prevails will unquestionably be a subject of debate 
in obstetrics for many years to come. The various discoveries which have 
culminated in the modern theory of the toxemia of pregnancy are herewith set 
forth, and, as far as possible, in their natural evolutionary sequence. 

1. The Relationship between Eclampsia and Renal Lesion. — Recognition of this relation- 
ship apparently marks the first step in the establishment of the theory of a toxemia of preg- 
nancy. Some years after Bright had described the phenomena of nephritis, we find Rayer 
(1840) announcing the discovery that eclampsia is preceded by albuminuria. It soon 
became obvious that the peculiar convulsions which from time immemorial have been 
known to menace the gravida were closely allied to the uremic convulsions which result 
from suppression of the renal function. At the outset the two series of parallel phenomena 
were regarded as identical, and Frerichs was satisfied to look upon gestational eclampsia 
simply as uremia; and therefore as due to self -poisoning from retained waste products. 

2. The Relationship between Acute Yellow Atrophy of the Liver and Pregnancy. — After 
Rokitansky had described this lesion of the liver in 1842, Frerichs was perhaps the first 
to collect the scattered observations and announce the fact that a very large proportion had 
occurred in gravidae. In other words, a second eminently toxic state, termed by Frerichs 
acholia, and by some of his successors cholemia, had a special predilection for this class of 



TOXEMIA OF PREGNANCY. 325 

patients. Clinically, this condition was known as icterus gravis; malignant, typhoid, or 
hemorrhagic jaundice, etc.; but as observations multiplied it eventually became probable, 
first, that acute yellow atrophy was only a high degree of acute parenchymatous hepatitis, 
both lesions giving rise to the same clinical picture; second, that jaundice was often but 
slightly marked and even absent altogether or present only as a terminal manifestation; 
third, that the term icterus gravis was applicable to a variety of conditions, in some of which 
the liver appeared to be unaffected. 

3. The Relationship between Eclampsia and Hepatic Lesion. — According to Vinay, 
recognition of the fact that in some cases of eclampsia the kidneys are normal, and that 
in these cases the liver is the seat of destructive lesion, goes back to the time of Frerichs 
and Karl Braun. Rokitansky is said to have pronounced certain cases of cholemia identical 
with uremia. It was eventually ascertained that, independently of the renal lesion, the 
liver was seldom or never free from alterations in eclampsia — these varying from minimal 
alterations to acute yellow atrophy itself. This line of research terminated in modern 
times in the claim of Jurgens that hemorrhagic hepatitis is in some degree characteristic 
of eclampsia. 

4. The State of ihe Liver in t Apparently Normal Pregnancy. — Tarnier is usually credited 
with the priority of the announcement that the liver almost invariably undergoes some 
change in all gravidas, such change consisting of a so-called steatosis or fatty infiltration of 
the parenchyma. From numerous scattered observations in literature, it is also apparent 
that higher degrees of degeneration are sometimes encountered at autopsies. It has long 
been stated that the liver of the gravida is prone to circulatory disturbances, and that its 
natural state is one of congestion. 

5. The Specific Kidney of Pregnancy. — It was believed originally that the gravida was 
unduly susceptible to Bright's disease, but in 1886 von Leyden recognized the specific 
character of the "kidney of pregnancy." He showed that the anatomical alterations are 
not inflammatory but degenerative in character, the renal epithelia undergoing a fatty 
infiltration. In the great majority of cases of women who survive eclampsia or fail to 
develop it, the pregnancy-kidney undergoes resolution after delivery, although prone to 
recur with succeeding pregnancies. The pregnancy-kidney develops during the latter half of 
gestation with albuminuria and cylindruria. Its debut is insidious and progress slow; 
eventually enough of the renal parenchyma is affected to cause more or less suppression 
of urine and a corresponding degree of oedema, which is confined as a rule to the lower half 
of the body. An autointoxication is now prone to occur, in which the suppression of urine 
plays a determining but not essential role. 

6. Bouchard's Researches into Autointoxication. — The work of Bouchard and his pupils 
undoubtedly gave a great impetus to the study of the toxemia of pregnancy. It was as- 
serted by this school that menstrual blood was hypertoxic; that after pregnancy develops 
the circulating blood has its natural toxicity increased, while the urinary toxicity is corre- 
spondingly reduced. After delivery, the blood appears to rid itself of its excess of toxic 
matter, the urinary toxicity becoming increased. Autointoxication, whatever its char- 
acter, was due largely to failure of the liver to perform one of its principal functions: viz., 
disintoxication of circulationg toxic bodies of whatever source. The poisonous matter 
might be derived from the food, from retained menstrual blood, fetal katabolic products, etc. 
According to these views, any pregnant woman might be looked upon as potentially 
autotoxic. 

Bouchard's methods of determining toxicity of fluids (amount per kilo of weight of 
animal required to kill an animal) were attacked as unsound, so that his conclusions have 
suffered as well. The latter, however, have been corroborated largely from other sources. 

7. Parallelism between the Hepatic Insufficiency of Clinicians and the Special Morbid- 
ity of Pregnancy. — The conception of hepatic insufficiency is one of the oldest in the history 
of medicine and was familiar to the ancients, as it is at present to the modern layman. It 
is expressed familiarly by such terms as "sluggish" or "torpid" liver, and also by "bilious- 
ness," or supposed minimal retention of biliary matter. The great authorities upon the 
liver have extended this conception in varying degrees, and numerous symptoms of hepatic 
insufficiency have been added from time to time. One of Bouchard's students — Bouffe 
de St. Blaise — calls attention to the striking parallel which exists between Hanot's sum- 
mary of the various symptoms of hepatic insufficiency and the special morbidity of preg- 
nancy. Common to each are the following: Alteration of character; lassitude; headache; 
insomnia or somnolence ; polyneuritis; visual disturbance; pruritus; ptyalism; dyspepsia, 
nausea and vomiting; constipation and meteorism; chloasma, epistaxis and bleeding of 
gums; urinary anomalies (diminished urea, increased uric acid, amino-acids and purin bases 
in urine, urobilinuria, alimentary glycosuria, albuminuria, etc.); varices; icterus; mania. 

8. Fatality of Epidemic Jaundice in Pregnant Women. — Vinay believes that the liver 
has a special vulnerability in the pregnant woman. The principal if not the sole ground 
for this belief appears to be the remarkable fatality of epidemic jaundice in the pregnant. 

9. Results of Experimental Extirpation, Destruction, and Isolation of the Liver. — Numer- 
ous experiments have been made in this direction, including the well-known work of Min- 
kowski (1897). When acetic acid is injected into the bile-ducts of dogs, thus producing 
destruction of hepatic tissue, hyperemesis is produced, and the animals perish in forty- 
eight hours with the picture of the terminal stages of acute yellow atrophy of the liver. 



326 PATHOLOGICAL PREGNANCY. 

Again, when the livers of geese are extirpated, urea disappears from the urine, being 
replaced by ammonium lactate. When an Eck's fistula is established in dogs between the 
portal vein and vena cava, the animals exhibit the cerebral phenomena of suppression of 
the hepatic functions, such as excitement, convulsions, stupor, or coma. If bile is injected 
into the blood, muscular weakness, hebetude, and coma are produced, but not convulsions. 
Hence clinically we can hardly attribute the phenomena of motor excitement to cholemia 
in the literal sense of the term. 

10. Heredity of Hepatic Insufficiency. — Some light may be thrown upon the vexed ques- 
tion of the special morbidity of pregnancy by the consideration of the element of heredity. 
No less an authority than Charcot has stated that hepatic insufficiency is preeminently 
an inherited malady. In support of this view Mile. Stein, in a recent Paris thesis,* cites 
cases which show that women who come of bilious or cholemic families have a marked 
tendency, when they become pregnant, to develop such symptoms as pigmentation of 
high degrees, bilious vomiting, albuminuria, alteration of character, etc. — in fact, the 
picture of medium grades of hepatic insufficiency. 

ii. Functional Paralysis of the Liver. Herz's Theory of Toxemia of Pregnancy. — 
The most puzzling feature concerning the toxemia of pregnancy is the inconstancy of 
the hepatic lesions. It being evident that the liver is primarily at fault in these cases, 
how explain the fact that its pathological alterations are sometimes minimal, or, according 
to some, wanting entirely? To answer this question we may assume from the analogy of 
nerve-tissues that the liver may in some cases be the seat of functional paralysis, and hence 
unable to discharge its functions. Some agencies may inhibit the action of the various 
hepatic enzymes without the production of structural change. As a rule, however, fatty 
degeneration occurs from lessened oxidation, or a certain amount of necrosis may be set 
up in the affected tissues by the action of the local enzymes. ■ This, of course, is pure 
hypothesis; but in no other way can we explain the extreme irregularity of the hepatic 
lesions. There is evidence to substantiate the claim that the liver may be the seat of 
functional paralysis; thus, when uremia is produced experimentally by ligation of the 
ureters, etc., the functions of the liver are suspended. 

If this hypothesis is accepted, it now becomes possible to set up a theory of the toxemia 
of pregnancy which is complete as far as it goes. This has, in fact, been done by Herz in 
his remarkable monograph, "Die Verdauungstorungen als Ursache und Folge anderer 
Krankheiten" (Berlin, 1898). 

Beginning with the suppression of the menses, it is stated that, however produced, — 
whether by simple amenorrhea, the menopause, castration, or pregnancy, — congestion of 
the liver results, being either habitual or limited to the menstrual epoch. Under certain 
conditions — as when the congestion is of a certain degree — we may look for associate phe- 
nomena, such as icterus (which sometimes represents vicarious menstruation), catarrh of 
the bile-ducts, and perihepatitis. The latter is stated by Rosenbach and others to be 
fairly common in pregnancy, and Herz himself has seen it on several occasions. It is also 
known to be prolonged into the puerperium and beyond. The cholangitis of pregnancy 
leads not rarely to the formation of gall-stones which are likely to be expelled soon after 
delivery. 

Coincident with these circulatory phenomena, we find other changes concerning the 
parenchyma and the functions of the liver, their relationship with the vascular changes 
not being absolutely clear. They are expressed anatomically by a tendency to fatty degen- 
eration, and functionally by evidences of hepatic insufficiency. 

While the functions of the liver are far from being understood, there can be no doubt 
that it is the chief organ for the elaboration and purification of the blood; so that the 
greater the degree of insufficiency, the greater the disturbance of metabolism and the 
more rapid the disintegration of the individual. In many cases the structural alterations 
keep pace with the failure of metabolism; hence it is not surprising in fulminant cases 
to find the entire liver destroyed (acute yellow atrophy). But numerous exceptions occur 
in which we may understand that a high degree of hepatic insufficiency exists without 
structural change; so that, as already stated, we are forced to assume the possibility of 
a functional paralysis of the liver. 

The kidney and spleen often suffer after the development of hepatic insufficiency, 
apparently from the extra burden thrown upon them. The renal lesion — namely, pregnancy- 
kidney — becomes an important determining factor in the commonest type of eclampsia; 
while the injury done to the spleen is held to be responsible for the development of anemia 
or leukemia in the post-puerperal period. 

In this connection we may mention a few other hypotheses which hardly require 
discussion under a separate caption. Dirmosier, reasoning from the benefit derived in 
threatened eclampsia from the absolute milk regimen and colonic irrigation, has put forth 
the view that the toxemia of pregnancy is due to absorbed ptomaines which the incom- 
petent liver is unable to disintoxicate. Others have sought to give significance to the 
occasional entry into the circulation of portions of placental villi or of liver-cells, holding 
that such structures may contain hostile enzymes which play havoc with the blood. 
Quincke has recently suggested that in certain cases the pancreatic juice may be forced 

*." Cholemie simple familiale et grossesse," Paris, 1903. 



TOXEMIA OF PREGNANCY. 327 

into the biliary canals and thus digest the parenchyma of the liver, although it is not easy 
to see wherein pregnancy favors such an accident. From quite another point of view, 
others have held that the liver — habitually overworked and vulnerable in pregnancy — 
may be unable to disintoxicate minute amounts of metalloid poisons — phosphorus, arsenic 
(from wall-paper?) and even alcohol. There may be a grain of truth in these hypotheses, 
as far as they affect individual cases. 

12. Hyperemesis and Pernicious Vomiting Due to the Toxemia of Pregnancy. Ewing's 
Theory of Toxemia of Pregnancy. — Working upon the preceding foundation, Dr. James 
Ewing,* Professor of Pathology in Cornell University Medical College, who has devoted 
himself especially to the study of this subject for the past seven years, has sought to enlarge 
the foregoing conception of the toxemia of pregnancy. Basing his views upon numerous 
autopsies at first hand, as well as extensive research into literature, he affirms his belief 
that most of the special morbidity of pregnancy is due to a basic autotoxic state, and goes 
so far as to include pernicious vomiting of the ordinary inanition type among the eminently 
toxic phenomena of the gravid state. There is, he states, no difference save in degree 
between the incessant vomiting of acute atrophy of the liver, etc., and the more lingering 
affection, which as a rule occurs independently of other manifestations. Hitherto hyper- 
emesis has been regarded as due chiefly to reflex irritation from the uterus, especially 
when acting upon a hysterical substratum. Ewing, however, has never yet failed to find 
lesions of the liver — albeit sometimes minimal and requiring the microscope for demon- 
stration — after death from pernicious vomiting. He also believes that whenever there 
are symptoms during life of marked hepatic insufficiency, the urine will show evidences 
of perverted metabolism; while at autopsy some lesion of the liver will invariably be found. 
He appears to discredit the authenticity of all paradoxical reports in which, with known 
destruction of the liver, the urine is stated as normal; and in which, with clinical evidence 
of acute hepatic insufficiency, the liver is reported free from lesion. For him these negative 
reports simply represent an incompelete investigation or defective methods. 

Ewing also lays great stress on the prolongation of the autotoxic state into and beyond 
the puerperium. This will be considered later (page 334). 

From all that has been stated under the introduction, it is evident that the 
status of the toxemia of pregnancy is sufficiently well established to admit of a 
statement of the etiology, pathology, symptomatology, clinical varieties, course 
and termination, diagnosis, prognosis, prophylaxis, and treatment. As far as 
is known, the subject in question has thus far never been dealt with in this 
systematic fashion, and I am under obligation to Dr. Ewing for filling out certain 
gaps in my attempts in this direction. 

Definition. — The toxemia of pregnancy may be defined as a state of the 
blood and metabolism arising from the hepatic insufficiency to which the preg- 
nant woman is strongly predisposed; expressed most commonly by trivial 
ailments (petty morbidity of pregnancy), but exceptionally by serious, severe, 
and even pernicious affections, such as acute yellow atrophy of the liver, per- 
nicious vomiting, eclampsia, — conditions which, while once thought to have 
nothing in common, are now seen to be closely related. 

Pathological Anatomy. — The anatomical alterations chiefly affect the 
liver, kidneys, and spleen. Exceptionally other organs may be involved, as 
peripheral nerves, thyroid, etc. The blood state in fatal cases resembles that 
of severe sepsis. Liver: Lesions of this organ are constantly present, but exhibit 
great irregularity in extent and severity. They are either degenerative or 
necrotic, the latter succeeding the former. We may encounter extensive areas 
of degeneration without necrosis, and, conversely, may see necrosis result from 
isolated foci of degeneration. A certain degree of fatty metamorphosis (stea- 
tosis) is said to be the rule in pregnancy ; and from these minimal changes there 
may occur a steady increase in intensity until acute parenchymatous hepatitis 
is reached, this condition consisting of an acute fatty degeneration, plus a 
proliferation of the interlobular connective tissue (Fig. 479). In like manner 
necrosis may develop in foci of fatty degeneration, and may occur in in- 
creasing severity until it culminates in acute yellow atrophy of the liver (Fig. 

* Professor Ewing's views are quoted from the MS. of an article now in preparation, 
to be entitled "The Toxemia of Pregnancy." 



328 PATHOLOGICAL PREGNANCY. 

480). Whenever necrosis reaches a certain stage the blood-vessels become 
involved, and hemorrhages and thrombosis may result. The most severe 
lesions of the liver are partly degenerative and partly necrotic; for this reason 
the size and appearance of the liver in the acute toxemia of pregnancy may vary 
greatly. In one instance the organ may be the seat of acute parenchymatous 
hepatitis with no diminution in size, while in another, the necrotic element is 
so marked that the size may be reduced to a third of the normal. Even in the 
midst of the extensive destruction, there is evidence of attempted regeneration 
of biliary canaliculi. Ewing, regarding necrosis of the hepatic cell as almost 
inseparable from the acute toxemia of pregnancy, gives the following degrees 
of intensity : Necrosis may be limited to individual isolated cells throughout a 
lobule ; or may involve the zone of cells between the central vein and periphery ;. 
or, finally, may involve the entire lobule, save a slight peripheric rim of cells- 
(Figs. 479, 480). Kidney: The appearances of the kidney are very irregular. 
Not only does the specific pregnancy-kidney occur under a variety of forms, but 
it may be complicated with nephritis, which affection may also occur de novo. 
Although some pathologists deny the existence of a specific kidney of pregnancy, 
the characteristics laid down by von Leyden appear to demonstrate the existence 
of a condition sui generis. From this point of view the pregnancy -kidney is an 
acute fatty infiltration of the kidney which does not compromise the integrity 
of the organ, and which tends to disappear after delivery. In rare instances 
acute toxemia of pregnancy is found to be associated with an acute parenchy- 
matous nephritis, terminating in atrophy. The connection of such a lesion 
with the specific kidney of pregnancy is a matter of speculation. Spleen: In 
acute toxemia of pregnancy, associated with hepatitis and necrosis of the liver, 
the spleen may be similarly involved. The damage thus inflicted upon this organ 
is held by some to account for the mysterious examples of anemia and leukemia 
which develop after the puerperium. Nerves: Polyneuritis occurs in the gravida 
to a greater extent than may be explained by chance. In some cases the phrenic 
nerve has been involved. Korsakoff's psychosis (mania with polyneuritis) has 
also been seen in the gravida. Thyroid: The normal enlargement of this organ 
in the gravida has been found wanting in certain cases of eclampsia. Blood: 
In high degrees of toxemia of pregnancy the blood shows characteristic changes 
which resemble those of sepsis. Thrombosis and embolism may occur, begin- 
ning in the hepatic veins. Another feature of this state is the acute hemor- 
rhagic diathesis, which leads to surface hemorrhages (petechias or extravasa- 
tions). Finally icterus may be enumerated among the symptoms of the acute 
dyscrasia of the blood. 

Etiology. — There are three sets of etiological factors which must be con- 
sidered in connection with the toxemia of pregnancy: (1) Conditions which 
predispose to hepatic insufficiency, comprising pregnancy itself, heredity and 
a previous history of toxemia. (2) Accessory factors which tend to modify the 
disease and cause it to assume special clinical types, and to influence the time 
of its appearance; these comprising nervous instability, the menstrual epoch, 
and mechanical factors. (3) Actual toxic substances in the blood, or toxic 
states of that fluid. The exact relation of this class of factors to the hepatic 
insufficiency is problematical, because a vicious circle is involved. Thus a 
toxic blood-state may by throwing additional work upon the liver cause a 
partial paralysis of its functions, which in turn causes the accumulation of more 
toxic matter in the blood. Each individual factor will now receive separate 
discussion. 

1. Pregnancy. — This is the sine qua non among etiological factors; for while 






a o a a w ■ , " o & " 



O Q ^ * 

• f> , « 






, , * 



, ' , ,' o 




Normal liver 
cells. 



Zone of in- 
tense gran- 
ular and 
fatty degen- 
eration. 



Zone of ne- 
crosis about 
centralvein. 



Fig. 479. — Toxemia of Pregnancy. Portion of an hepatic lobule from a case of the toxemia 
of pregnancy. Specimen show.s intense granular and fatty degeneration, and also zone 
of necrosis about the central vein, x 75 diameters. — (From a specimen in the Patholog- 
ical Laboratory of the Cornell University Medical College.) 



TOXEMIA OF PREGNANCY. 329 

many of the phenomena of the toxemia of pregnancy may occur in the non- 
pregnant, some of the lesions of the liver and kidney appear to occur only in 
gravidity, while clinically the course of the malady is intimately bound up with 
gestation. The frequent — yet by no means universal — cessation or great 
amelioration of the symptoms after death of the fetus or emptying of the uterus 
is alone sufficient evidence of the specificity of this affection. The relationship 
of pregnancy to the autotoxic state is considered more fully under pathogeny. 
Hereditary, Congenital and Acquired Tendency to Hepatic Insufficiency: For the 
great influence of heredity in this connection see page 336. Doubtless this sort 
of insufficiency might also be contracted in utero from imperfect development, 
and also in extra-uterine life as a result of diseases of the alimentary canal, 
liver, kidneys or heart, of chronic infectious or dyscrasic conditions, of alco- 
holism — in fact, of any state whatever in which the liver may have been 
unduly overtaxed. Previous History of Toxemia of Pregnancy: In a large pro- 
portion of cases one attack appears to predispose to another at a consecutive 
pregnancy. This is especially likely to happen if the first attack was of suffi- 
cient severity to produce structural alterations of the viscera. Even in the 
absence of a history of toxemia, the mere fact that children of a given woman 
are born in rapid succession is said by Ewing to furnish a very strong predispo- 
sition; for the toxemia, however slight or latent, may become cumulative. If 
the toxemic symptoms are not resolved after delivery and persist into the lacta- 
tion period, conception would likely be followed by toxemia in an aggravated 
form. In this connection we may cite the statement by Ewing that in some 
cases of dysmenorrhea antedating conception the women exhibit evidences 
of a toxic condition resulting apparently from suppression of the menses. 
A woman of this sort is notably predisposed to toxemia in case of con- 
ception. 

2. Accessory Factors. — Numerous factors help to shape the course of the 
toxemia. The nervous instability which, according to von Herff, is almost 
inseparable from pregnancy, and which perhaps is itself evidence of an autotoxic 
state, undoubtedly plays a very prominent role — in proportion to its degree — 
in the causation of paroxysms of vomiting and eclamptic convulsions. If reflex 
irritation is the factor in the morbidity of pregnancy which many assume, it 
can be such only through the accession of nervous instability. An important 
factor for determining the onset and exacerbation of symptoms is the time of 
the menses. Thus hyperemesis may first set in or become much aggravated or 
develop terminal symptoms, at the end of the various months of pregnancy. 
When the increase of the ovum and uterus is of such extent as to raise the intra- 
abdominal pressure, compress important organs, and interfere with circulation 
and respiration, this mechanical factor often becomes of great significance in the 
development of pregnancy-kidney, and other conditions — constipation, for 
example — which may increase the severity of the autotoxic state. 

3. Toxic Substances and Influences. — (1) Nitrogenous substances derived 
either from katabolic activity or from the ingesta are most commonly suspected 
of participating in the toxemia of pregnancy. The failure of the liver to syn- 
thetize the lower nitrogenous products of katabolism to urea and uric acid is 
held to be responsible for the accumulation of these substances in the blood. 
There are included here amino-acids, ammonia, xanthin bases, etc. However, 
but one of these — carbaminic acid — is a known chemical poison; and this has 
not yet been found in the blood in toxic quantities. If the toxic state already 
exists, a nitrogenous diet appears to favor greatly the development of convul- 
sions; this fact arguing that the peptones and peptoids of digestion normally 



330 PATHOLOGICAL PREGNANCY. 

require disintoxication by the liver before they are fit for assimilation. Finally, 
nitrogenous products of putrefaction, ordinarily rendered harmless by the liver, 
may be pathogenic in the gravida — although generally speaking ptomaine 
poisoning does not greatly resemble the acute toxemia of pregnancy. (2) Bile: 
From the frequent use of the term cholemia as a synonym for toxemia of preg- 
nancy, it might be thought that the condition represents an absorption or 
suppression of the bile. This is not the case, however. Bile when injected 
into animals possesses narcotic properties, but there is not much evidence that 
bile per se or the substances from which it is produced plays any important 
role in the genesis of the autotoxic state of the gravida. At the same time it 
is by no means impossible that such is the case. The subject is considered more 
fully under pathogeny. (3) Changes in the normal alkalescence or concentration 
of the blood may be responsible for the toxic phenomena. Thus the same dimi- 
nution of the alkalescence which is known to exist in diabetic coma (so-called 
acid-intoxication) may be noted in the acute toxemia of pregnancy. This is 
held to be due to the presence of "acetone bodies " (acetone, aceto-acetic acid), 
of lactic acid and the higher fatty acids, and probably represents imperfect 
oxidation of carbohydrates. In this condition the urine gives an intense acid 
reaction. The opposite state of increased alkalescence is seen under experi- 
mental conditions (Eck's fistula) and perhaps clinically as well — as in cases in 
which the breath, urine, etc., are ammoniacal. It has also been claimed that 
the accumulation of unsynthetized antecedents of urea and saline matter which 
occurs from imperviousness of the renal filter produces the picture of uremia 
merely by increasing the ionic concentration of the blood, and that uremia may 
be produced experimentally by filling the circulation with concentrated solu- 
tions of salts. If this is true, something analogous doubtless occurs in eclampsia. 
(4) Occasional or Chance Poisons: Since the liver of the gravida is in a state of 
exhaustion, it is well to bear in mind that it may not be able to fix and neutralize 
ordinary poisons of alien source which have a special tendency to injure it. 
These comprise phosphorus, arsenic and antimony, alcohol when taken habitu- 
ally, and perhaps other substances of a similar nature. Bacterial toxins and 
foreign enzymes must also be borne in mind as chance factors. 

Pathogeny. — Pregnancy itself is doubtless the efficient cause of the hepatic 
overwork, for the liver presides over anabolism and must be largely concerned 
in the upbuilding of the fetus. The importance of the hepatic tissue to the 
growing organism is best seen in the disproportionally large size of the liver in 
the fetus and infant. It is often stated that the maternal liver should not be 
overtaxed in the early months of pregnancy; and this may be true in the sense 
that the products of embryonal katabolism must be insignificant; we must 
bear in mind, however, that during the embryonal period a rapid organogenesis 
occurs; and that the various tissues and organs are all rapidly evolved from a 
relatively undifferentiated matrix. It is commonly affirmed that this rapid 
differentiation is accomplished by the aid of enzyme-like bodies, which are 
generated, do their work, and give way to others. TVhile it is often said that 
the maternal blood contains all these potentialities for fetal development, 
it would be more nearly correct to state that this responsibility is invested in 
the chief hematopoietic organ — the liver. 

To this drain upon the liver must be added the influence of suppressed men- 
struation in the gravida, which is said to entail congestion of the liver, and per- 
haps also an increase of tension, or the retention of toxic substances in the cir- 
culation. If, now, the various predisposing causes are borne in mind, as 
heredity, previous toxemia of pregnancy, etc., we may readily conceive of causal 



o 




<J 






9^ fijv 



Peripheral 
row of in- 
tact cells. 




Narrow zone 
of very fat- 
ty cells. 



Edge of area 
of necrotic 
and disin- 
tegrated 
cells, which 
occupy in- 
ner two- 
thirds of 
lobule. 



Fig. 480.— Toxemia of Pregnancy. Portion of an hepatic lobule from a case of pernicious 
vomiting of pregnancy. Specimen shows fatty degeneration and necrosis.— {From a 
specimen in the Pathological Laboratory of the Cornell University Medical College.) 



TOXEMIA OF PREGNANCY. 331 

factors wlaich may explain the "failure of the, liver " even when it occurs, as in 
rare cases, early in pregnancy. 

As pregnancy advances the risk increases. Thus the gravida after subsidence 
of preliminary nausea, etc., may develop a voracious appetite, and may take 
large quantities of nitrogenous food. The steady growth of the uterus and 
ovum must add in time to the katabolic work of the liver. The increase of intra- 
abdominal pressure must be prejudicial to the work of that organ; and the 
obstinate locking-up of the bowels which frequently occurs must favor the 
absorption of putrefactive products. The woman cannot exercise, and her 
respiratory activity is prejudiced. To all these contingencies must be added 
the possibility of some bacterial infection, an addiction to alcohol, or some form 
of drug-poisoning, as from arsenical wall-paper, " complexion wafers," etc. 

Symptomatology. — Some of the more important and constant symptoms 
require special attention. These may be grouped under the following heads: 
viz., gastro-hepatic, urinary, nervous, and cutaneous. G astro-hepatic: While by 
no means constant, pain and tenderness over the epigastrium and right hypo- 
chondrium are not infrequent. The area of hepatic dulness may be increased. 
This class of symptoms may be due to a variety of causes — hepatic congestion, 
perihepatitis, soreness of muscles from vomiting, and in some cases actual in- 
flammation of the liver. Urinary: In high degrees of toxemia unsynthetized 
nitrogen compounds appear in the urine at the expense of the urea (ammonia 
compounds, amino-acids, purin bodies). In some cases leucin may be present as 
a result of destruction of liver tissue. Generally speaking, the urinary findings 
in the toxemia of pregnancy are sufficiently numerous and varied to discourage 
classification. They tend to show that various phases of hepatic insufficiency 
may occur irrespective of other changes. Nervous: This class of symptoms 
is characteristic of the toxic state. Alteration of character may be of the same 
nature as the moody, peevish, and irascible "spells" which result from bilious 
crises. An increase in reflex excitability may account for some of the mor- 
bidity of the gravida. In higher types of toxemia an increase of cortical activity 
is shown by intense restlessness, agitation, insomnia, convulsions, delirium, etc. 
This class of symptoms may be followed or replaced by the opposite group — 
apathy, hebetude, somnolence, stupor and coma. Headache may be mentioned 
in this connection. In some cases the nerves are directly attacked by a circulat- 
ing poison (polyneuritis). Cutaneous: Several cutaneous symptoms of pre- 
sumably toxic origin — pigmentation, pruritus, etc. — are discussed in the section 
on Skin Diseases in Pregnancy (page 380). The relationship of the pernicious 
impetigo herpetiformis to the toxemia of pregnancy has not been determined. 
Ewing regards it as belonging here. Although heretofore looked upon as a 
septic condition with metastases to the skin, — death occurring usually from 
pneumonic deposits, — the prominence of vomiting as a symptom is worthy of 
mention, as suggestive of the autotoxic state. Jaundice in the gravida is a 
subject of unusual interest. Despite the frequency of hepatic insufficiency in 
the gravida, icterus appears to be quite rare, and when present due in some 
cases to mere coincidence, as simple obstruction, etc. When we come to the 
association of jaundice with severe affections of the gravida, the obscurity 
increases. For a long period icterus, usually of high degree, was held to be 
part of the clinical picture of acute yellow atrophy of the liver; and icterus 
gravis and malignant jaundice were synonymous with this condition. To-day 
the term icterus gravis is used in quite a different sense. Quincke * applies it to 
Weil's disease. Others use the term in a more generic sense, as applicable to 
* Nothnagel's "Handbuch d. sp. Pathol." 



332 PATHOLOGICAL PREGNANCY. 

any pernicious affection accompanied by severe jaundice, when well-known 
conditions like yellow fever and pyemia can be excluded. 

We are concerned here only with jaundice occurring as a result of hepatic 
insufficiency in the gravida. It appears to be uncommon not only in mild, but 
even in severe degrees of toxemia. Even in complete paralysis of the hepatic 
functions, it may appear only as a terminal manifestation, and may even be 
absent altogether. The conclusion is forced upon us that icterus is not a common 
expression of hepatic insufficiency; that in benign cases it is due to simple mechan- 
ical obstruction of the biliary passages, and in grave cases to a general dissolu- 
tion of the blood. Nevertheless, in very rare cases we do find icterus, perhaps 
of high degree, as an expression of the toxemia of pregnancy. Acute yellow 
atrophy of the liver usually coexists, but in certain paradoxical cases a corre- 
sponding lesion of the kidney is the principal finding. In severe jaundice occur- 
ring independently of acute yellow atrophy, the metabolism, as shown by urin- 
ary analysis, resembles that of the latter condition, suggesting perhaps a func- 
tional paralysis of the liver. All things considered, the occurrence of icterus 
in high degrees of the toxemia of pregnancy is best explained by the supposition 
of a dissolution of the blood, such as is known to occur in fatal cases. 

Clinical Types. — The toxemia of pregnancy may be classified in various 
ways from the clinical standpoint. Thus in regard to intensity or duration, we 
may recognize fulminant, acute, subacute, and chronic — or, better, benign types. 
With reference to the sequence of reproduction, we may recognize gestational 
and post-partum types, and may subdivide each group into early and late; late 
post-partum developments, however, are rather to be regarded as sequelae, 
the result of injury to the spleen. We may also talk of recurrent types. From 
the standpoint of the implication of special organs, we may recognize hepatic \ 
renal, splenic (?), cerebral, and other local types, bearing in mind that the 
peripheral nerves are sometimes attacked to the exclusion of other lesions. 
From this standpoint of dominant symptoms, we may speak of hy per erne sis y 
eclampsia, icterus, etc., as characterizing the toxemic state. Some cases of 
gestational psychosis may belong here. 

Fulminant Types. — The toxemia of pregnancy — as expressed by acute yellow 
atrophy of the liver — has been known to cause death within twenty-four 
hours. Under such circumstances we expect to see a violent toxemia leading 
rapidly to coma and death. Ewing goes even further, and states his belief 
that cases of paradoxical sudden death in the gravida are sometimes due to the 
autotoxic state. Here the toxemia may either pursue a latent course, or death 
may occur from heart-clot, pulmonary embolism, or cardiac paralysis. 

Acute Type. — The clinical picture of acute toxemia of pregnancy, while it 
varies notably in individual cases, is constant in certain respects. It may be 
divided into three stages, which are present in typical cases. The first — which 
may be termed premonitory or initial — consists of prostration, headache, and 
vomiting. In some cases this stage may pass unobserved; in others the acute 
type develops on a background of toxic symptoms of moderate severity, which 
have persisted for weeks. The second stage is preeminently neuropathic in 
type, the cerebral cortex and nerve-centers in general being involved. It 
is expressed by restlessness, agitation, insomnia, mental confusion, etc., pass- 
ing into convulsions, maniacal excitement, and delirium. The terminal stage 
is one of apathy, hebetude, somnolence, stupor, coma, and death. In 
some individuals, either from intensity of toxemia or temperamental pecu- 
liarities, the second stage is not in evidence, the patient passing at once into the 
terminal stage. Under these circumstances convulsions may be absent. The 



TOXEMIA OF PREGNANCY. 333 

symptoms of the premonitory stage usually increase in intensity with the further 
development of the disease. Headache may become intense and vomiting 
incessant. The so-called "black vomit" may appear, and an unquenchable 
thirst may develop from the constant rejection of fluids. 

Other symptoms of acute toxemia exhibit the greatest inconstancy. This 
is true especially of fever, jaundice, and the state of the urine. 

From both the clinical and anatomical standpoints we may speak of the acute 
toxemia of pregnancy as typical and atypical. In typical cases the liver is the 
seat of notable lesions — acute parenchymatous hepatitis or acute yellow atrophy. 
Clinically, we find notable tenderness, and sometimes pain and tumefaction, in 
these viscera. In atypical cases, despite the apparent suspension of the hepatic 
functions, the anatomical findings vary greatly. The liver may appear normal, 
while some other important organ is extensively involved. Authors write in 
this connection of acute atrophy of the kidneys, meningitis, etc. Ewing insists 
that in all these atypical cases a careful search will discover necrotic areas or 
extreme granular and fatty degeneration in the liver. 

As may readily be inferred my description of the acute toxemia of pregnancy 
corresponds closely with the acute yellow atrophy of text-books. It is, how- 
ever, a much more comprehensive term, and therefore represents a condition 
by no means as rare as its prototype. Since the latter was originally supposed 
to be accompanied by severe icterus, the recorded material is unduly small. 

Characteristic of the acute toxemia of pregnancy is its unexpected appear- 
ance and its extreme fatality. Despite the forerunners which in theory should 
constitute danger-signals, experience teaches that this condition may appear 
without warning — often in women who are apparently in robust health; and 
at any stage of pregnancy (even at the beginning of the second month). Re- 
covery must be a very rare termination of this condition; and the favorable 
-outcome which has been claimed for individual cases is so infrequent as to dis- 
credit the accuracy of the reports. The fetus usually dies before expulsion, for 
the acute toxemia of pregnancy does not, as a rule, tend to interrupt gestation 
in any other fashion. As might be inferred, emptying the uterus is without 
influence on the course of the disease. Survival of the child, however delivered, 
is a rare exception. 

Subacute Type. — In this type death is not inevitable, and when it results is 
not due necessarily to the direct action of the toxemia. The chief varieties of 
the subacute toxemia are, expressed clinically, eclampsia and hyperemesis; 
and in both these conditions we may infer the cooperation of a neuropathic 
substratum, in virtue of which the convulsions or vomiting, once established, 
contribute to the death of the individual. The ability to control these pheno- 
mena exerts a notable influence on prognosis in these states. Termination of 
pregnancy also tends to exert a salutary influence, although numerous exceptions 
•occur. On account of their marked clinical individuality these two conditions 
are discussed separately. We may here emphasize certain differences between 
the acute toxemia of pregnancy and eclampsia. In its typical form the latter 
occurs only at a late stage of pregnancy, and is clearly determined by the ante- 
cedent development of the pregnancy-kidney. This lesion, while in itself 
•evidence of an autotoxic state, doubtless depends largely on the presence of 
mechanical factors. The hepatic lesions of typical eclampsia, while character- 
istic, are not extensive, and the moderate degree of toxemia which coexists is 
clearly aggravated by the obstruction of the renal filter. Eclampsia, therefore, — 
unlike the acute toxemia, — is amenable to relief by a general eliminative and 
dietetic plan of treatment. The prophylaxis of eclampsia is almost a matter 



334 PATHOLOGICAL PREGNANCY. 

of certainty; yet this does not reach the essential cause of the disease, but only 
its complications. Ability to control the convulsions improves the prognosis, 
and termination of pregnancy also holds out hope of recovery. 

Transitions naturally occur between the acute and subacute types of tox- 
emia. Thus a case which clinically appears to be eclampsia may be found at 
autopsy to present no pregnancy-kidney, but extensive structural changes in 
the liver. Again, pregnancy-kidney may not lead up to convulsions, but to a 
stuporous state, the patient dying apparently from the direct action of the 
toxemia. 

The relationship of pernicious vomiting to acute toxemia is less apparent. 
(See under Nausea and Vomiting in Pregnancy.) 

Benign Type. — The special petty morbidity of pregnancy, which according 
to some authors is the minimal expression of the autotoxic state, comprising 
nausea and simple vomiting, anorexia, perverted tastes, chloasma, vertigo, 
constipation, pruritus, etc., demands little attention here. It is of significance 
principally in calling attention to the disposition to toxemia. But even from 
this point of view it is of doubtful significance, first, because of its great fre- 
quency, and, second, because in the great majority of cases the condition is 
self-limited, the symptoms disappearing as pregnancy advances. The latter 
fact appears to show that the maternal organism is able to throw off the toxemia. 
This may come about through a sort of compensation — other organs assuming 
the excess of work done normally by the liver — or through the formation of 
disintoxicating agencies, which are able to neutralize the toxic principles which 
accumulate in the blood. Of much interest here is the discovery by Klein that 
the normal gravidic hypertrophy of the thyroid does not occur when pregnancy- 
kidney develops. 

Course, Termination, and Sequelae. — These have been considered in the 
preceding sections. The acute toxemia is probably invariably fatal, although 
recovery seems to have occurred from analogous conditions in the non-pregnant. 
While it tends to destroy the patient rapidly, it has been known exceptionally 
to persist for months. Death usually occurs within a week after the super- 
vention of the nervous stage, and may result in a few days or even hours. 

Fetal death or emptying the uterus appears to exert no salutary effect; 
nor is the condition always amenable to disintoxicating methods, or to any treat- 
ment whatever. Persistence through and beyond the puerperal state could 
only occur as a rare exception, death being none the less inevitable. 

The course and termination of subacute toxemia are discussed under Nausea 
and Vomiting of Pregnancy, Polyneuritis and Eclampsia. 

Mild or benign toxic symptoms often cease spontaneously in the course of 
pregnancy itself, and in any case they usually disappear after delivery. Ewing 
states that in some cases hepatic insufficiency persists after delivery. The 
commonest actual sequelae consist of blood changes ; paralysis following neuritis ; 
and occasional nephritis developed from pregnancy-kidney. Ewing believes that 
puerperal sepsis may often be practically a sequela of the toxemia of pregnancy, 
through furnishing a strong predisposition to infection. 

Diagnosis. — Here' are comprised the recognition of the various degrees of 
hepatic insufficiency, beginning with the mild or benign types and ending with 
complete paralysis; the recognition of the various associated blood-states; 
and, finally, the characterization of the particular clinical type. It is therefore 
requisite in all suspected cases to make a physical examination of the liver and 
spleen, and to have the urine analyzed by an expert, with special reference to 



TOXEMIA OF PREGNANCY. 335 

the detection of unsynthetized nitrogenous bodies, and organic acids. The 
patient may be tested on alimentary glycosuria. It is, of course, highly im- 
portant to measure the work of the kidneys. In theory, a blood examination 
should be valuable, but the simpler tests would not yield much information, 
while a quantitative or physico-chemical analysis would not be possible in 
routine work. The nervous system should be examined, because the degree of 
nervous instability is a factor of importance, and the disposition of the toxemia 
to attack the higher nerve-centers must be borne in mind. Further, it is im- 
portant to recognize the evidence of a hysterical element when this is present; 
also mechanical factors and chance complications. 

Whenever a pregnant woman is taken violently ill, we must always bear in 
mind the possibility of a fulminant type of the toxemia of pregnancy. It 
is here that the condition is usually misunderstood; and mysterious cases 
of sudden death, alleged suicides or accidental poisonings, supposed instances 
of acute meningitis or of fulminant infectious disease, may perhaps have been 
examples of the most intense degree of toxemia of pregnancy. To make an 
exact diagnosis in these cases may not be possible. 

In the ordinary acute type, when typical, a diagnosis should readily be made 
from a physical examination of the liver, and the results of the urinary analyses, 
together with the rational signs. 

In the rare cases in which the liver appears normal or the urinary examina- 
tion is negative the diagnosis is of course difficult. In these anomalous cases the 
patient may appear to suffer from some profound infection or intracranial dis- 
ease. 

The diagnosis of the subacute types of toxemia will be considered under 
Hyperemesis, Eclampsia, Polyneuritis, etc. 

Recognition of the milder degrees of toxemia demands no special considera- 
tion. Ewing advises that in all cases of suspected toxemia of pregnancy, and 
especially whenever a woman begins to vomit, the urine should be carefully 
examined for leucin and tyrosin. Indeed, one might well go further and examine 
the urine of all gravida? for these bodies. The finding of leucin and tyrosin 
need not be set down straightway as evidence of toxemia ; but if the latter were 
really present, other evidences, including those furnished by the urine, would 
doubtless coexist. Mere examination of the sediment of a fresh urine is not 
sufficient.* 

Prognosis. — This is good in the benign forms of toxemia. In the acute 
and fulminant types the prognosis is nearly hopeless, since the mortality has been 
almost universal. For the prognosis of eclampsia, hyperemesis, etc., see subse- 
quent sections. Richard C. Norrisf is inclined to regard some cases of sudden 
death in the puerperium as due to cardiac failure induced by the direct action 
of the autotoxic blood-state upon the cardio-vascular system. 

Treatment. — As for prophylaxis, a woman who seems to suffer much con- 

* The following procedure is adequate and expeditious, but will require a hydrogen 
sulphide generator: To ioo c.c. of urine add 25 c.c. of a clear saturated solution of basic 
acetate of lead, which preciptiates albumin, phosphates, and chlorides. Filter, bringthe 
filtrate to the boiling-point, and remove the excess of lead by a current of ammonium 
sulphydrate, continued for at least fifteen minutes. Filter again and evaporate the 
filtrate to a syrupy consistence over a water-bath. Leucin crystals are readily identified 
microscopically as clusters of yellowish spheres exhibiting radiating and concentric striae. 
Tyrosin crystallizes in various forms, but can be identified only when occurring as clusters 
of acicular crystals which are very refractive and appear almost opaque. Further identi- 
fication of crystals consists in determining their solubilities as described in text-books 
on chemistry. 

f " Effects of the Toxemia of Pregnancy upon the Cardio-vascular System," "Amer. 
Jour. Obstet.," July, 1903, pp. 31, 104. 



336 PATHOLOGICAL PREGNANCY. 

stitutional reaction during menstruation should be carefully watched during 
gestation. Charcot states that a functionally incompetent liver is very likely 
to be inherited ; therefore a woman whose ancestors and kindred show a marked 
tendency to "hepatism" should run more risk in becoming pregnant than one 
without this ancestry. Finally, a woman in whom symptoms of toxemia appear 
to persist during the period of lactation should by all means avoid a second con- 
ception until complete recovery has occurred. For other resources read sec- 
tion on Etiology. 

The curative treatment demands a careful study of the symptoms in all cases, 
and prompt action in most. Mild toxemia, so called, requires only expectant 
management. 

Despite the apparently hopeless outlook in acute toxemia, I strongly recom- 
mend in all cases the same general line of treatment as that I set down for the 
Preventive Treatment of Eclampsia. (See pages 350 and 351.) In addition 
to the exclusive milk diet, and the stimulation of the action of the liver, 
bowels, kidneys, skin, and lungs, I have found repeated colonic irrigation and 
infusion, and intravenous infusion of the decinormal saline fluid, valuable. 
On account of the diminished alkalescence of the blood, alkalies are indicated 
in theory, as they are in diabetic coma, in which state they have produced some 
benefit. Bearing in mind that the hepatic lesion may in a given case be due in 
part to a bacillus, methylene-blue, which is eliminated by the bile, should be 
of value as an antiseptic. 

My views upon the evacuation of the uterine contents are the same here as 
in the Preventive Treatment of Eclampsia. 

Conclusion. — It will be asked, no doubt, "Why devote so much space in a 
text-book to a condition like the acute toxemia of pregnancy, which apparently 
is rare, and can seldom be foreseen, and, thus far, has almost resisted treatment? " 
My answer is, that it represents a phase of our knowledge which is in its infancy, 
and a subject which will, in my belief, come in time to throw light on many 
dark places in obstetrics. Acute toxemia of pregnancy is not as rare by any 
means as is generally believed, and is a most insidious affection when it does 
occur, masking itself, as it does, under various clinical pictures. 

If unrecognized, it may lead to suspicion of poisoning, suicide, or some other 
type of preventable death. We might, in a general way, compare the recog- 
nition of this state with the discovery of ptomaines and ptomaine poisoning, 
in regard to practical significance. Again, it may some time be possible to fore- 
see, prevent, and cure this condition when not of the fulminant type. Recovery 
is not uncommon after acute phosphorus-poisoning, thereby showing the regener- 
ative power of the liver. 

2. Nausea and Vomiting in the Pregnant Woman. — This subject is considered 
under the toxemia of pregnancy largely because in fatal cases hepatic lesions 
of the same character as those which occur in eclampsia and acute yellow 
atrophy of the liver may usually be found; also because severe vomiting is a 
prominent symptom of many toxemias. If vomiting in the pregnant is fre- 
quently spoken of as hysterical in character, it must be borne in mind that 
this refers only to the clinical expression of the symptom. 

(1) Simple (So-called Physiological) Vomiting. — Slight nausea, with 
or without vomiting, occurs in about one-half of all pregnancies, and in the 
vast majority of primiparse; the symptom appears about the end of the first 
month, and is usually associated with perversions of taste. There may be 
general anorexia, repugnance to certain articles of diet, and unnatural cravings 
for others not usually appetizing. Considered in their totality, symptoms refer- 



NAUSEA AND VOMITING IN THE PREGNANT WOMAN. 337 

able to the digestive tract are almost universally present in pregnancy; those 
who escape nausea or perversions of taste and anorexia may suffer from hyper- 
orexia or bulimia. These symptoms usually persist until the middle of the 
fifth month, when they subside spontaneously, and appetite and normal tastes 
return. 

In their simplest expression the nausea and vomiting of pregnancy bear a 
notable resemblance to the morning- vomiting of the alcoholic subject, appearing 
as a rule upon rising from the recumbent position. Retching may be the only 
active symptom, or actual vomiting of mucus, gastric juice, or biliary matter 
may occur. The woman is usually able to eat breakfast, and has no further 
gastric disturbance during the day. In rare instances the nausea and vomit- 
ing occur in the latter part of the day or during the night. In the next higher 
degree the woman vomits during or after the meal. She is, however, usually 
able to continue eating and to retain the food ; so that there is no real interfer- 
ence with nutrition. 

In a still higher degree nausea is more than a momentary affair, and persists 
for several hours, often accompanied by ptyalism and distress in the epigastric 
region; vomiting is then slow to occur, and is much more distressing than usual. 
In all degrees up to this point there is no necessary interference with nutrition, 
and no absolute refractoriness to treatment. 

(2) Hyperemesis. — When vomiting is of a higher degree than those just 
described, and associated at the same time with evidences of gastric insufficiency, 
such as drowsiness, nightmare, etc., and with some interference with nutrition, 
we may term the condition hyperemesis. As long as this state is amenable 
to ordinary treatment, we should not term it incoercible or pernicious. The 
women, while they cannot retain certain articles of food, have no trouble with 
others; and it is sometimes possible by simple diet and symptomatic remedies 
to overcome the condition, although there may often be some failure of 
nutrition. 

Vomiting of pregnancy sometimes pursues an anomalous course, without 
regard to its severity. Thus, it may begin immediately after conception, as if 
it were an expression of suppressed menstruation. The ordinary appearance of 
vomiting coincides with the period of the second (suppressed) menstrual period. 
The usual time of cessation of vomiting corresponds to "quickening" of the 
fetus. In a few cases the disappearance of vomiting may be succeeded bv 
diarrhea. It has also been noted that a strong mental impression about this 
time will cause the sudden cessation of vomiting. In a small proportion of 
cases the latter symptom is prolonged to term, and in another series of cases 
the gastric disturbances set in about the middle of pregnancy. This relation 
to suppressed menstruation, with the occasional resemblance to the morning 
vomiting of alcoholic subjects, suggests the presence of a toxic element, even 
in so-called physiological and benign degrees of vomiting; as does also the 
coexistence of numerous symptoms mentioned under Benign Toxemia of 
Pregnancy. (See page 334.) 

Most standard authorities, including gastro-intestinal specialists, continue to 
refer benign vomiting of pregnancy to uterine irritation, due to compression of 
the uterine nerves by the growing uterus in general, added to abnormal uterine 
distention, malpositions, cervicitis, etc., in particular. Reflex vomiting some- 
times occurs in pelvic affections of the non-pregnant. But it is generally ad- 
mitted that an increased nervous excitability furnishes a predisposition ; and we 
must not forget that this exalted sensibility, wherever found, is itself attributed 
by many to an autotoxic state of the same nature as that which is produced 
22 



338 PATHOLOGICAL PREGNANCY. 

by nervous exhaustion. Quite recently Dr. M. Knapp, of New York, has denied 
the existence of reflex vomiting. 

Treatment. — Benign vomiting may be relieved by simple measures, such as 
breakfast in bed before assuming the erect posture; the use of concentrated 
liquid food; anesthesia of the stomach by a few drops of laudanum; readily 
digestible solid food ; sparkling wines, or alkaline effervescent waters ; aromatics; 
cracked ice, etc. After eating, recumbency should be maintained. Recent 
clinical experience has caused me to look with suspicion upon even benign 
vomiting, as the expression of a mild toxemia of pregnancy, and to treat it 
accordingly, namely, by a restricted diet; stimulating the action of the liver, 
bowels, skin, and lungs, and by colonic irrigation and infusion. 

(3) Incoercible or Pernicious Vomiting. — Introduction. — Heretofore 
this term has been employed to designate a continuous condition of emesis in 
the pregnant, which when uninfluenced by treatment leads in a few weeks to 
gradual death by inanition. Only in very recent times has a single authority — 
Ewing — sought to extend the term to the vomiting which accompanies acute 
conditions, such as acute yellow atrophy, cholemic eclampsia, and -perhaps 
ordinary renal eclampsia, and which may be a prominent or indeed the principal 
symptom of this class of affections. Under such circumstances the woman 
suffers from an eminently acute general disease, resembling at times an acute 
systemic infection. There is a marked clinical resemblance between these 
fulminating affections and typical incoercible vomiting, and Ewing regards the 
two types as essentially the same ; since in the ordinary inanition type he finds 
at autopsy hepatic lesions of the same character as those which occur in the 
fulminant type. As the latter is amply considered under the heads of acute 
toxemia of pregnancy, icterus gravis (acute yellow atrophy), cholemic eclampsia, 
etc., I shall only allude to it in the present connection in a casual way; reserv- 
ing the term "pernicious vomiting" to the classical inanition type of disease. 

Etiology and Pathogenesis. — Perhaps we are justified in the conclusion that 
the gravida, by reason of her digestive disturbances, her nervous irritability, 
her pelvic irritation, and her supposedly toxic blood-state, is especially pre- 
disposed to vomiting; and if she suffers concurrently with some affection which 
in itself is associated with a tendency to provoke emesis, we can readily under- 
stand that the latter might assume the incoercible or pernicious type. Hence 
pernicious vomiting may be divided into symptomatic and idiopathic types. 
In the former the autotoxic state goes no further than the production of 
increased reflex excitability, the determining cause of the vomiting being a 
local lesion, usually of the stomach, bowels, peritoneum, uterus, brain, etc. 
Accidental toxic blood-states — typhoid fever, variola, etc., and even uremia — 
do not appear to be able to determine pernicious vomiting. 

Symptomatic Type. — Under this head I consider the part played by 
affections of local organs in setting up pernicious vomiting. Stomach: Ordi- 
narily even in severe cases of vomiting of pregnancy, lesions of any sort are 
absent. But, exceptionally, pernicious vomiting has been found at autopsy 
to have depended on gastritis (sometimes of alcoholic origin), gastric 
ulcer, and even cancer of the stomach. Hence the stomach must always 
be carefully examined by modern diagnostic procedures. Liver: The pres- 
ence and passage of gall-stones have been known to cause obstinate vomiting 
in the pregnant, as has also cancer of the liver. Of great significance in this 
connection is the vomiting which forms a leading symptom in icterus gravis 
and the cholemic form of eclampsia, in both of which affections the liver is the 
seat of extensive lesions. In any destructive affection of the liver, whether 



NAUSEA AND VOMITING IN THE PREGNANT WOMAN. 339 

due to yellow fever, phosphorus poisoning, or the conditions just enumerated, 
blood may be washed into the bile, and after reaching the duodenum may be 
vomited, causing the so-called "black vomit." Clinically, incoercible emesis 
may be the chief and most constant symptom ; and Professor Ewing, of Cornell 
University (see "Toxemia of Pregnancy"), having found hepatic lesions in cases 
of apparently uncomplicated pernicious vomiting, has assumed that a toxic state 
manifested incidentally by alterations of the liver is responsible for all fatal 
cases of this affection. That some of these women may be saved by psycho- 
therapy is, in his opinion, no argument whatever against the hepatic origin of 
the phenomenon. It is evident that this matter cannot be decided until a 
large number of livers of pregnant women dead of pernicious vomiting have 
been studied minutely. Certainly if a high degree of hepatic necrosis brings 
about incoercible vomiting in a fulminant manner, leading rapidly to "black 
vomit" and death, it does not appear unreasonable to suppose that a less severe 
participation of the liver may give rise to a subacute type of vomiting, with 
gradual production of inanition. Therefore in all cases of severe vomiting of 
pregnancy the urine must promptly be examined for evidences of hepatic in- 
sufficiency and hepatic destruction. We should look especially for leucin, uro- 
bilin, and sugar; and the excretion of urea should be estimated. If the vomited 
matter contains anything suggestive of blood, it should be examined for hepatic 
detritus. Intestine and peritoneum: Both intestinal obstruction and peritonitis 
(usually tuberculous), in their capacity of inducing vomiting, have been at the 
bottom of some cases of incoercible emesis. Some cases of the latter have 
appeared to be due to nothing more than constipation — a fact to be borne in 
mind in the management of these cases. Kidney: Any acute lesion whatever 
of this organ, which tends to produce suppression of urine and uremia, whether 
or not associated with the typical kidney of pregnancy, may in theory cause 
obstinate vomiting in pregnancy; but, as already stated, the pregnant woman 
exposed to true uremia usually appears to escape its active manifestations. 
The urine must, of course, be carefully examined. 

The relation of anomalies of the genitals to the vomiting of pregnancy is 
much more obscure, for naturally the peculiarities of the gravid uterus, its 
overdistention and displacements, are not often imitated in the non-gravid 
woman; so that it is not easy to trace any absolute connection between uterine 
conditions and vomiting. It is commonly taught that in subjects with predis- 
position, various anomalies of the gravid uterus excite reflex vomiting; the 
proof being found in the fact that the vomiting sometimes ceases as soon as 
these local conditions are rectified. But in these women of hysterical disposi- 
tion, it is a notorious fact that recovery from serious maladies may come about 
in the most bizarre manner. 

However, there is no reason to doubt that the nervous instability of the 
pregnant woman is under the influence of peripheral irritation, and that in 
certain cases such irritation may induce phenomena which are out of all pro- 
portion to its own magnitude, just as in appropriate subjects pressure on hystero- 
genous zones may cause convulsions, and certain forms of local irritation cause 
reflex epilepsy. To sum up, vomiting in a gravida may be due to uterine 
irritation; but if recovery follows removal of the latter, we are not justified 
in asserting that the malady was of reflex origin. Thus the vomiting may 
have been due to some of the other conditions which we have mentioned, and 
vStill have yielded to the strong mental impression produced by dilatation or 
cauterization of the cervix or other procedure directed to the uterus. 

Idiopathic Type. — If we can exclude the presence of organic or functional 



340 PATHOLOGICAL PREGNANCY. 

affections which set up vomiting in the non-pregnant, and if any anomalies 
of the uterus have been corrected without any corresponding improvement 
in the woman's condition, we may consider the case one of uncomplicated 
pernicious vomiting, and due wholly to the toxemia of pregnancy. We 
may postulate the existence of a hysterical or toxic substratum, and may 
even assume that these two elements are radically the same. But the problem 
faces us of determining the presence of something upon which to base an indi- 
cation for treatment. Does the hysterical or the toxic element predominate? 
Or is neither in evidence? If the woman is markedly hysterical, the stigmata of 
hysteria should be present. Vinay has often found in such patients a neuro- 
pathic ancestry, a history of hysteria, amyosthenia, anesthesia of the conjunctiva 
and pharynx, cutaneous hemianesthesia, narrowing of the field of vision, and 
hysterogenous zones. Moreover, he has sometimes found that vomiting has 
begun after some strong mental impression. Whether or not evidences* of 
hysteria are present we should always note the presence or absence of the symp- 
toms of the chronic toxemia of pregnane) 7 , as described on page 331. As these 
are of common occurrence and as pernicious vomiting is rare, we cannot straight- 
way conclude that the latter is the result of the former, but in the absence of 
any hysterical element we are perhaps justified in this conclusion. The result 
of pernicious vomiting, as shown by beginning disassimilation, must not, of 
course, be confounded with a coexisting toxic state. However, it is not impos- 
sible that the toxic state which accompanies hyperemesis is the result and not 
the cause of that condition; and that the constant waste of gastric juice by 
removing some unknown principle (internal secretion) which is necessary to the 
organism brings about at last a state of autointoxication characterized, as a 
rule, by tetany, increased reflex excitability, convulsions, coma, and death. 
Such a condition has been produced experimentally by allowing the gastric 
juice of the dog to escape constantly through fistulous openings (von Mering); 
and an analogous state has been noted in man after persistent vomiting, and 
even after excessive lavage of the stomach (Kussmaul). 

Symptomatology. — However produced, the symptoms of incoercible vomiting 
run a tolerably constant course. Since the time of Dubois the symptomatology 
of pernicious vomiting of pregnancy has been divided into three stages, this sub- 
division being of use in connection with prognosis and treatment. First Stage: 
The initial symptoms tend to appear either in the first two months or not until the 
sixth or seventh month. They are encountered but rarely between the third 
and sixth months and not at all after the seventh. The very earliest phenomenon 
consists of slight repugnance toward certain articles of food, with possibly a 
craving for others not usually fancied. Vomiting then supervenes, the patient 
having as many, perhaps, as twenty or thirty attacks in twenty-four hours. At 
first only articles of food are ejected, but eventually mucus, bile, and even blood. 
As a result of the vomiting the patient becomes constipated, emaciated, and feeble. 
Dubois considered the first stage essentially one of emaciation, the natural result 
of the continuous vomiting. Second Stage: After a time fever is added to the pre- 
ceding picture. The skin becomes hot and dry, the pulse small and rapid. This 
febrile condition is apparent rather than real, and despite the hot skin, quick pulse, 
scanty urine, etc., the temperature is but slightly elevated or not at all. The patient 
becomes weaker and thinner and the urine shows the presence of albumin and casts. 
There is tenderness over both the epigastrium and the uterus. If the patient is 
subjected to daily weighing, the loss of weight will be seen to be continuous. A 
daily loss of over 10 ounces (300 grams) is serious, while one of 5 to 7^ ounces 
(150 to 200 grams) is much less significant. Weakness is shown especially in 



NAUSEA AND VOMITING IN THE PREGNANT WOMAN. 341 

attacks of syncope when the patient attempts to rise. The second period may 
extend over a number of weeks, and at any time during its course interruption 
of pregnancy may save the patient's life. The original gastric symptoms persist 
unchanged during this period. Third Stage: If the patient once develops the 
phenomena of the third stage, it is considered almost impossible to save her life. 
The characteristics of this stage are : vomiting which is less marked and which may 
even disappear, so that the patient is able to retain food. The relatives cherish the 
delusion that the patient is about to recover. The other symptoms, however, do 
not improve. The pulse remains weak and rapid, thirst is extreme, the surface 
of the body becomes cold, the abdomen collapsed, etc. To these are added 
symptoms especially characteristic of the third stage, most of which have a cere- 
bral origin. Intense headache or neuralgia may supervene, the sight and 
hearing become impaired, the pupils contracted, the voice altered. Jactita- 
tion sets in and is followed by somnolence and coma. Hallucinations are not 
uncommon. Death of the inanition type occurs in a few days after the super- 
vention of the third stage. The complications most commonly encountered are 
diarrhea, icterus, and hypostatic pneumonia. For several years past I have 
been accustomed to describe two varieties of hyperemesis, presenting to me two 
distinct clinical pictures: the first a reflex, neuropathic or hysterical condition 
with no symptom of any toxic state of the blood and quite readily held in 
bounds by treatment or disappearing spontaneously; and a second, a toxemia 
depending upon some unknown poison in the blood, with symptoms of languor 
sometimes approaching stupor, general malaise, headache, constipation, itching 
of the skin, insomnia or somnolence, dizziness, alterations in character and 
disposition with slight lapses of memory. This last, or toxemic hyperemesis, 
I have looked upon as a serious condition, one difficult to control by medicinal 
remedies and usually demanding the termination of pregnancy for its relief. 
The march of the disease may extend at most two or three months, this in- 
cluding remissions which are sometimes present. The duration of the first 
stage depends much on its severity. If the patient vomits twenty or thirty 
times daily, or, in other words, if there is complete intolerance to food, the so- 
called second stage, representing the complete development of the malady, will 
soon appear. The duration of this stage depends naturally upon the rapidity of 
loss of weight; and, of course, upon the success of treatment and occasional 
spontaneous remissions. After the premonitions of death appear in the 
nervous disturbances, the end usually occurs in two or three days; exception- 
ally, considerably later. Generally speaking, the course pursued is that of 
dying by starvation. In quite recent years the diazo-reaction has been found 
to develop in pernicious vomiting, and is interpreted as a grave prognostic sign 
and indication for the termination of pregnancy. Pernicious vomiting may or 
may not undergo a spontaneous cure if the fetus dies. Too much dependence 
should not be placed on this association. Out of 46 fatal cases no less than 
18 patients died after spontaneous or induced abortion. Another mode of 
termination is that first pointed out by Cazeaux, who showed that patients 
recover unexpectedly under the operation of strong mental impression. In other 
cases the disease subsides without any apparent cause. 

Diagnosis. — The existence of the condition cannot be doubted, but the 

cause should be carefully sought. There are three points * which must be 

observed in making this diagnosis: (1) the existence of pregnancy must be 

proved; (2) the cause of the vomiting must be demonstrated; (3) the differ- 

* Gueniot: "Brit. Med. Jour.," 1886. 



342 PATHOLOGICAL PREGNANCY. 

ential diagnosis between the obstinate vomiting of pregnancy and that due to 
other causes having no connection with gestation must be made. 

Prognosis. — This will depend upon the cause. If of symptomatic or 
hysterical origin, the prognosis is favorable. If essentially autotoxic, the 
prognosis may be good if the pregnancy is terminated. In spite of an early 
emptying of the uterus fatalities will occur. The nutrition and vitality of the 
fetus are good under the circumstances. 

Treatment. — Although I am not convinced that all cases of pernicious vomit- 
ing of pregnancy have an autotoxic origin, still I believe that a large proportion 
of these cases are due to hepatic insufficiency and toxemia, and that the best 
results will be obtained by treatment directed to this cause. Hence while 
not ignoring entirely the value of hygienic, dietetic, medicinal, and even local 
treatment, I advise that treatment be promptly directed to the correction of 
an hepatic insufficiency and toxic blood-state, whether the clinical picture of 
the toxemia of pregnancy is present or not. Regulate the diet, and if neces- 
sary, nourish by rectal feeding; stimulate the liver and bowels by a full dose 
of calomel, and secure the action of the drug by high enemata of sulphate of 
magnesia; secure free action of the kidneys by diuretics, the free ingestion of 
plain water or colonic infusion of decinormal saline solution; cause the skin to 
act with hot packs and use oxygen freely for the lungs. Frequently repeated 
colonic irrigation and infusion are most valuable to relieve the toxemia or hepatic 
insufficiency and the intense thirst so often present. Likewise in severe cases 
intravenous infusion of the saline solution will prove valuable, and it should 
be resorted to early and repeated if necessary. My views upon the evacuation 
of the uterine contents are the same here as in the Preventive Treatment of 
Eclampsia. 

The hygiene of the patient should be carefully regulated; kind treatment and 
pleasant surroundings are of the greatest value; sexual intercourse is to be pro- 
hibited; in grave cases the patient should remain in bed and perfect quiet and rest 
be enjoined. Many cases can be improved if the patients can be made unconscious 
of the fact of swallowing, either by spraying the fauces with a solution of cocain or 
by the use of the esophageal tube. Liquid food, such as milk and lime-water, eggs, 
beef -juice, koumyss, or clam-broth, should be tried; and if moderate quantities 
are rejected, the food should be given in teaspoonful doses at short intervals ; 
at times it is most acceptable if given with cracked ice, in other cases very hot 
milk or broths are retained. Somatose and panopepton are of value. 

'Medicinal. — Among the medicines that are useful are the oxalate of cerium, 
in doses of from five to ten grains (0.3 to 0.6 gm.), with or without the subnitrate 
of bismuth; iodine (Churchill's tincture), one or two drops well diluted; menthol 
and cocain, either as a spray or internally, in small doses ; carbonic-acid water, 
in small quantities or ad libitum; the same with the addition to each siphon of a 
drachm (4 gm.) of the bromide of potassium; tincture of nux vomica in ten-drop 
doses for gastric catarrh, and pepsin with diluted muriatic acid after food. Klein - 
wachter uses creosote, 15 minims (1 gm.) three times a day, combined with citrate 
of caffein and gentian, as an intestinal antiseptic. The inhalation of oxygen 
is serviceable even early in the disease. Nerve sedatives are sometimes very 
useful; the bromide of potassium or of sodium, with or without chloral, may be 
given in full doses per rectum. Codein may be given by the mouth or morphin 
hypodermatically; the latter may be given endermatically over the epigastrium 
when local tenderness exists. Other remedial agents are counter-irritation 
or the ether spray over the epigastrium, or the application of ice to the cervical 
vertebrae. Cases of success by the use of the electric current have been reported, 



NAUSEA AND VOMITING IN THE PREGNANT WOMAN. 343 

the faradic current being passed through the stomach. Believers in the hysteri- 
cal theory apply the measures which are most efficacious in the treatment of 
that affection. Thus, the woman may be separated from her friends and relatives 
and placed in a sanitarium. Sometimes the mere threat of isolation has pro- 
duced a cure. 

Local. — Malpositions of the uterus, and engorgement or hypertrophy of the 
cervix, should be corrected; erosions may be touched with a 10 per cent, solu- 
tion of silver nitrate or with pure carbolic acid; the application of cocain to the 
cervix and the vault of the vagina has been reported to be successful in some 
cases. I have never found it of value. Dilatation of the internal os with a 
glove-stretcher dilator, so as thoroughly to rupture the circular fibers at this 
point, is occasionally a successful procedure. At the same time any endo- 
trachelitis, or erosions of the portio vaginalis, should be attended to. I have 
repeatedly found that attention to these matters has apparently effected a cure. 
I have dilated the internal os in primigravidae, curetted the cervical canal, 
scraped the cervix itself free from erosions, applied pure carbolic acid to the 
cervix and canal, and relieved the symptoms, without interrupting pregnancy, 
in a number of cases given up as hopeless and sent to the hospital to have labor 
induced. The finger will occasionally serve as a dilator, and in every case the 
greatest care must be used not to rupture the membranes. 

Induction of Labor. — This will become necessary when there appears no 
other way of saving the mother, but we must never wait too long before resort- 
ing to this means, for although the vomiting always stops with the evacuation 
of the uterus, the woman may die from exhaustion. 

Rectal Feeding. — This may become necessary, and should not be delayed too 
long. The physician must ever bear in mind that rectal alimentation has its 
time limit, that it cannot be continued for weeks, as some suppose; for during 
this time the patient grows progressively weaker, and the induction of labor is 
finally resorted to, too late to save the mother's life. Rectal feeding has been 
attended with variable results in the vomiting of pregnancy. Most commonly 
the injections have consisted of beef -tea, albumin water, defibrinated blood, 
brandy, milk, and peptones. A few drops of laudanum are sometimes added. 
Rectal injections must be given in small quantities, not more than five or six 
ounces, for fear of causing local irritation. At times the mere efforts of vomiting 
are so great as to cause the expulsion of the enema. The rectum should first be 
cleansed by the injection of a quart of water containing a teaspoonful of salt. 
One hour after the resulting evacuation the first rectal feeding should be 
given. Any kind of a syringe may be connected with a soft-rubber rectal tube 
and the nutriment thrown slowly into the bowel. The tube is then withdrawn 
and the patient instructed to lie quietly, in order that the enema may be retained. 
Three to five nutrient injections of from five to ten ounces may be given daily. The 
followingsubstanc.es are recommended for feeding: (i) Commercial peptones and 
propeptones, two or three ounces in each injection. Commercial beef -juices. (2) 
Milk and egg, a sort of eggnog, containing six or seven ounces of milk and one 
or two raw eggs, a teaspoonful of powdered sugar, a large pinch of salt, and a 
tube of Fairchild's pancreatin. (3) Pancreatized meat, five ounces of minced 
raw beef, one or two of fresh pancreas, an ounce of butter, and six ounces of water, 
all well compounded. These enemata should be given in rotation. In addition, 
the body receives a supply of water by daily rectal injection of saline infusion.* 
Pancreatized milk made with Fairchild's pancreatin may be used, also defibrin- 
ated blood. Flint's formula — milk 2 ounces (60 c.c), whisky half an ounce 
* Einhorn: "Post-Graduate," New York, July, 1900. 



344 PATHOLOGICAL PREGNANCY. 

(15 c.c.), with one half of an egg — may be used. Leube's pancreatic meat 
emulsion is a good preparation: 3 to 10 ounces (90 to 300 c.c.) of very finely 
chopped beef, one-third the quantity of minced pancreas (pig or ox), with the 
addition of lukewarm water and mixed in a mortar to the consistency of a thick 
soup. After each rectal injection the patient should retain the recumbent posi- 
tion on the left side with hips raised, for a time, while the nurse supports the 
anal region with a towel. Posenheim's formula is: glucose half an ounce; 2 
eggs; peptone 1 to 2 drachms, and half an ounce of emulsion of cod-liver oil. 
Six per cent, solution of cocain should be applied to painful hemorrhoids. 

3. Icterus. — Icterus being but a symptom, and very infrequent as a com- 
plication, of the toxemia of pregnancy, I do not give it special consideration. 
Frequent references to the subject will be found under " The Toxemia of 
Pregnancy." 

4. Convulsions and Coma. — The highest clinical expression of the toxemia 
of pregnancy concerns the cerberal cortex, being manifested by increased motor 
excitability and convulsions, on the one hand, and somnolence, stupor, and 
coma on the other, the latter symptoms usually succeeding the former. In 
the great majority of cases the involvement of the higher nervous centers cor- 
responds to the typical gestational or puerperal eclampsia of authors, which 
is associated with albuminuria and the pregnancy-kidney. But in a wider sense, 
other convulsions and comatose conditions occur in connection with maternity, 
which, while more or less closely related to eclampsia proper, differ in certain 
respects, either of pathogenesis or clinical expression. These atypical manifesta- 
tions comprise the following: (1) Cholemic eclampsia; (2) true uremic convul- 
sions and coma; (3) incidental convulsions of severe general diseases, acute or 
chronic; (4) epilepsy and hysteria major; (5) eclampsia without convulsions; 
and (6) other stuporous and comatose states. 

(1) Cholemic Eclampsia. — This is a clinical transition between the acute 
toxemia of pregnancy and ordinary eclampsia. (See page 334.) Its existence 
appears to be established by the labors of Braun, Frerichs, Stumpf, and others. 
It is a rare form of disease and is characterized both by its pathological anatomy 
and clinical course. Its prodromes are also characteristic, as there is nothing here 
to point to renal mischief. Albuminuria and cylindruria, ischuria, and oedema 
are absent, as a rule; and are replaced by symptoms pointing to the liver, 
such as epigastric tenderness, vomiting, intense headache, and pain referred to 
the liver. Then a state of nervous agitation is developed, which may become 
maniacal in character. Convulsions follow and the patient sooner or later 
becomes comatose. In the more severe cases jaundice always develops, although 
it may appear tardily and to but slight degree. Fever is the rule, but in a 
personal case of Vinay's there was hypothermia. The pulse may range from 
100 to 120 and upward. The characters of the urine are inconstant. In one 
case it may contain biliary matters, and in another may be normal. The 
cholemic state may be well developed, as shown by the condition of the blood, 
which favors thrombosis, embolism, and hemorrhage. Petechias and purpura 
are common. Cerebral apoplexy has been noted. 

At autopsy the liver is usually found to be the seat of lesions. Vinay states 
that in a few cases nothing at all may be found, even with the microscope. 
Minimal lesions are sometimes encountered, such as capillary hemorrhages. As a 
rule, however, there is more or less necrotic change, amounting in its highest degree 
to acute yellow atrophy (Figs. 479, 480). While the more severe and fatal cases 
of cholemic eclampsia possess considerable individuality, the milder forms may 
readily be overlooked during life, i. e., they may pass for ordinary eclampsia, 



CONVULSIONS AND COMA. 345 

especially if the urine contains albumin. In some cases a diagnosis of cholemic 
eclampsia has been made from abnormalities of the urine, as urobilinuria and 
glycosuria (Stumpf), conditions which point to hepatic insufficiency. 

(2) True Uremic Convulsions and Coma. — Care must be exercised in 
approaching this subject, for ordinary typical eclampsia is often termed uremic 
because of the renal lesion, and evidence of urinary suppression which are so 
often present. It is evident that a pregnant woman, like any other, may 
develop an acute nephritis, for example, after scarlatina; and that from the 
sudden suppression of urine, she may develop the entire picture of uremia, 
including convulsions. Acute nephritis may be developed upon an ordinary 
pregnancy-kidney, and confusion necessarily arises as to whether the case is one 
of simple uremia or eclampsia. A subacute nephritis may first become manifest 
in pregnancy, and by undergoing an exacerbation cause true uremia. But the 
ordinary chronic interstitial nephritis, — contracting kidney, — the very affection 
which is invariably sure to produce uremia in time if the patient survives 
long enough, appears to be little affected by pregnancy; and in only an insignifi- 
cant percentage of cases do pregnant women thus afflicted develop convulsions. 
This fact has doubtless done more than any other to convince obstetricians that 
some radical differences underlie uremia and the toxemia of pregnancy. 

Differences between Uremia Proper and Eclampsia. — Here is doubtless the 
place to touch upon this subject. Uremia appears to be a condition which 
develops either from a sudden suppression of urine or when the parenchyma 
of the kidney has been slowly destroyed. Eclampsia develops in the same 
manner, when the pregnancy-kidney has reached a certain stage in its de- 
generative course. Thus far the two conditions agree fairly well. But eclamp- 
sia also develops in pregnant women when the urea excretion is still normal, 
and even in cases in which the kidney shows no lesion whatever and albumin 
is absent. Therefore while uremia may be set down to simple suppression of 
urine, eclampsia rather suggests the operation of a vicious circle, in which a 
circulating poison first injures the kidney, and the kidney being more or less 
compromised has its function partially suppressed. The circulating poison, how- 
ever, can cause a condition akin to uremia when the kidney remains normal. 
Aside from differences in pathogenesis, the toxic substances concerned must, 
if not the same, be closely allied. Several minor points of difference have been 
described. Italian obstetricians have claimed that dyspnoea, one of the most 
constant symptoms of simple uremia, is not encountered in the eclamptic con- 
dition. It has also been claimed that the freezing-point depression (cryoscopic 
point) of the blood differs in the two conditions. Dyspnoea, already alluded to, 
is said to be an early and constant symptom of true uremia, which greatly 
aggravates the natural dyspnoea of pregnancy. Since uremia implies a perma- 
nent discontinuance of the renal functions, it should lead to a fatal termination, 
delivery conferring no permanent benefit upon the woman. Eclampsia, on the 
other hand, is not necessarily fatal, and the pregnancy-kidney then undergoes 
resolution. 

(3) Incidental Convulsions of Severe General Diseases. — In theory 
these might occur under a variety of conditions. Vinay mentions only one of 
diagnostic significance: viz., acute meningitis. Terminal convulsions might 
occur in various maladies, and be recorded as puerperal eclampsia. The subject 
does not appear to have attracted much attention. 

(4) Epilepsy and Hysteria Major. — These affections, when they occur 
in the pregnant woman, would come under a general heading of gestational 
convulsions. While a few attacks of epilepsy occurring during a pregnancy in 



346 PATHOLOGICAL PREGNANCY. 

a known epileptic possess only a superficial analogy to eclampsia, the reverse 
is the case in severe forms, including the subintrant type and status epilepticus. 
Here the patient may pass directly from one convulsion to another, and exhibits 
the same stuporous and febrile condition as the eclamptic patient, the picture 
being one of the severest intoxication. The renal function is not compromised, 
nor is the liver known to be involved in any way; it is conceivable, however, 
that the circulating poison may be the same in the two conditions. The status 
epilepticus {grand mal type), like the highest degree of eclampsia, is almost 
invariably fatal. 

What has been said of epilepsy applies almost verbatim to hystero-epilepsy. 
Here we may also see subintrant convulsions and a status hystericus, which, 
however, has not the fatal character of the terminal epileptic manifestations. 
Hysteria, however, does not appear to be an intoxication; and the absence of 
any evidence of toxemia is often of great service in diagnosis. The nervous 
instability which underlies eclampsia and epilepsy is present in the highest 
degree in hysteria, and convulsions may be incited by pressure over hystero- 
genous zones. This community of predisposition may justify us in mentioning 
hysteria major in this section. As far as the convulsions proper are concerned, 
they may occur in precisely the same fashion in all three maladies. Epilepsy 
and hysteria will be mentioned again under Diagnosis (page 349). 

(5) Eclampsia without Convulsions. — This condition is simply what 
its name implies: viz., the entire clinical picture of eclampsia, its prodromes, 
headache, epigastric pain, fever, stupor, etc., but minus the motor excitation 
and convulsions. Owing to the slight degree of intoxication in some cases, 
the disease does not pass beyond the prodromal state, this abortive form being 
often in evidence when treatment, or rather prophylaxis, has been instituted 
seasonably. Cases may be of such gravity that they pass almost directly into 
coma after a single convulsion. Thus understood, a separate clinical variety of 
eclampsia without convulsions is hardly justifiable, for this should mean 
only very slight or very profound degrees of intoxication. A few cases 
in which convulsions are absent, and stupor the leading feature, have been 
reported. 

(6) Other Stuporous and Comatose Conditions. — The stupor and coma 
which follow epileptic convulsions and status epilepticus respectively should be 
mentioned here. In some cases the coma which sets in during eclampsia and 
uremia is due to the supervention of cerebral apoplexy. Alcoholic coma may, 
of course, occur in a pregnant woman. 

5. Eclampsia. — See also Toxemia of Pregnancy. — Definition. — By the terms 
eclampsia, puerperal eclampsia, and puerperal convulsions, is meant, in modern 
medicine, an acute morbid condition, making its advent during pregnancy, labor, 
or the puerperal state, which is characterized by a series of tonic and clonic con- 
vulsions, affecting first the voluntary and then the involuntary muscles, accom- 
panied by complete loss of consciousness, and ending in coma or sleep. The 
disease may eventuate in death or recovery (Charpentier). Eclampsia may be 
gestational, intra-partum, and post-partum, or puerperal eclampsia proper. 

Frequency. — Eclampsia occurs most often in the latter part of gestation, 
less often in labor, and least of all in the puerperium. The estimation of 
its frequency has been variously tabulated as 1 in 500 pregnancies, 1 in 250 
to 300, 1 in 350 to 500 — a variation of from 2 per cent, to 4 per cent. The com- 
plication is stated to appear in 1 per cent, of all cases of albuminuria of preg- 
nancy. Schauta believes it to occur in 25 per cent, of all pregnancies. I found 
in 1200 cases of confinement, 800 of which were out-patient cases, that eclampsia 



ECLAMPSIA. 347 

occurred in 7 cases, or 0.58 per cent., or 1 in 171 cases. In another series of 
1000 hospital cases it occurred in 3 cases, or 0.30 per cent., or once in 333 cases. 
Of the 10 cases, 8 occurred at the tenth month, 1 at the sixth, and 1 at the fifth. 

Etiology. — There is much work still to be done on this subject, but it is 
well known that eclampsia is not always dependent on albuminuria and altera- 
tion in kidney tissue, and also that albuminuria is not always present during 
the convulsions. Many theories have been propounded to explain the phenom- 
ena of this affection. 

Predisposing causes may be considered under three classes: (1) All chronic 
and acute diseases of the kidney; the forms of nephritis; inflammatory changes, 
whether old or recent ; the recent kidney of pregnancy ; all of which are followed 
by failure in elimination, hydremia, albuminuria, and oedema. (2) Retention 
of urine, if extreme and of long duration, especially that caused by pressure 
on the ureters. This pressure may be due to (a) abnormal enlargement of the 
uterus, as in the case of twin pregnancy, hydramnios, etc.; (6) small pelves; 
(c) large fetus or fetal head. As proof of this cause statistics show the occur- 
rence of eclampsia in 11 per cent, of multiple pregnancies, in comparison with 
the 1.1 per cent, of single pregnancies. (3) It has been noted, also, that primi- 
paras of extreme youth or extreme age are especially liable to eclamptic attacks, 
on account of the rigidity of their muscles, and the limited space in their pelvic 
and abdominal cavities. The proportion of eclamptic primiparae to multiparae 
is as 3 to 1 (Schauta). 

Exciting Causes. — Exciting causes, when abetted by predisposition, may 
consist in (1) the abrupt suppression of urine, be it partial or complete; (2) 
constipation; (3) painful contractions of the uterus, or a rigid os or introitus 
vaginas, in primiparae; (4) extended and exhausting expulsive efforts; (5) 
excessive emotion. When once the eclamptic convulsion takes place, the 
most trivial shock, internal or external, may cause a renewed paroxysm. 

Pathology. — The pathology of this condition is most obscure. Post-mortem 
examination of the organs shows a general anemia, a congested cerebral cortex, 
now and then slight apoplexies in the liver, and a fluid condition of the blood. 
It is interesting to note, however, that the most important alterations, de- 
creased urinary toxicity and corresponding increase in amounts of the poisons 
circulating in the blood, are found more strikingly intra vitam than after death. 

Symptomatology . — The symptoms of eclampsia may be considered under 
the prodromal period, or pre-eclamptic state, and those occurring during the 
attack. In the latter there are three stages: (1) invasion; (2) tonic and clonic 
convulsions; (3) coma. Prodromal period, or pre-eclamptic state: The symp- 
toms of this stage are very important, for they offer a certain warning of an 
impending attack. There may be, as in epilepsy, a well-defined aura. After 
this, or even without it, there may be headache, tinnitus aurium, visceral dis- 
turbances, such as dizziness, amblyopia, amaurosis, epigastric pain, digestive 
and nervous disturbances, and a feeling of general debility. These are fairly 
constant in about one-fourth of all cases of eclampsia. At times there may 
be symptoms of involvement of the brain, stupor or insomnia, vertigo, vomiting, 
mental excitement, or despondency. These may all disappear, in which case 
there is a return of appetite, a more abundant perspiration and diuresis, and 
the patient falls into a refreshing sleep. Generally, however, the result is 
not so favorable, and the premonitory signs, or pre-eclamptic state, after last- 
ing for several hours or days, give place to those of the stage of invasion. There 
is convulsive twitching of the lids, the eyes stare, and the pupils, which were 
at first contracted to a pin-point, are widely dilated. During the attack there 



348 PATHOLOGICAL PREGNANCY. 

is total insensibility to light. The face is cyanotic, and there is rapid and 
convulsive jerking of the muscles about the alae of the nose and the mouth. 
The mouth is contracted to one side, there are rotation of the head and rolling 
up of the eyeballs. This is followed by the stage of tonic and clonic convul- 
sions. The movements, which at first concerned only the head, now extend 
to the neck, trunk, and extremities, very infrequently, however, passing to 
the lower extremities. The neck is bent backward, and at last, together with 
the back, forms an opisthotonic curve; there are extension and rigidity of 
the arms, clenching of the hands, with the thumbs in the palms, and flexing 
of the knees on the abdomen. The respiratory muscles, including the dia- 
phragm, are involved by the tonic convulsions. Although the muscles of the 
chest are firmly contracted, there may be one or two spasmodic respirations 
at the height of the paroxysm. The tongue partly protrudes and, since it 
is often bitten, the saliva, which is frothy, is colored with blood. There is 
complete loss of sensation and of consciousness. The duration of the tonic con- 
vulsions is from ten to twenty seconds, and they are followed by clonic spasms. 
The clonic convulsions, as in the first of the attack, begin in the face, which 
becomes horribly distorted, and then extend over the body. Irregular and 
noisy respiration takes place, there are rapid opening and closing of the jaws, 
and the tongue may be again bitten. The patient may have to be held in 
bed, but generally the body retains its previous position. Eclampsia closely 
follows epilepsy in many clinical features. Thus, there are overlapping (sub- 
intrant) convulsions, a status convulsivus or continuous paroxysmal state (status 
epilepticus, status eclampticus), and an exhaustion-paralysis or temporary loss 
of motor power in the convulsed muscles in both diseases. At the end of the 
attack full, labored, and stertorous respiration occurs. In one or two minutes 
follows the stage of coma. The duration of this period is about half an hour. 
Consciousness and sensation are slow to return. If a favorable issue is to take 
place, the patient falls into a deep sleep, and awakes to ask confusedly what 
has happened. After this stage mothers have denied their offspring born dur- 
ing eclampsia. Rarely there is but a single attack, and as a rule a number 
occur at varying intervals. If the seizures cannot be controlled, and death 
is inevitable, there are a progressive rise of temperature to 104 F. (40 C.) 
or more, and a small, rapid, wiry pulse. A semi-unconscious state follows, 
and death may occur during this period, or in the course of an attack, from 
pulmonary oedema, cerebral congestion, hemorrhage, or exhaustion. Patients 
who have survived the disease proper may die during the puerperium of some 
intercurrent affection. 

The Effect upon the Fetus and Labor. — One attack is often sufficient to kill the 
child. In twin pregnancy the death of one or both children may occur. How- 
ever, the child may survive several attacks. Winckel notes an interesting fact, 
that if the fetus is killed and pregnancy not interrupted immediately, labor 
both in its onset and course may be free from convulsions. In view of the 
shock, nervous disturbance, and uterine contractions, there is apt to be an 
abrupt termination of pregnancy. If the attack takes place in labor, there 
is increase of the pains from general muscular excitement, so that the child 
may be born while the physician is engrossed with the care of the mother. 
There is involvement of the kidneys in about two-thirds of the cases of eclamp- 
sia. In 84 per cent, the urine contains albumin, varying in quantity even 
to 2.5 per cent., or higher. There are an increase of albuminuria with each 
attack, and a rapid decrease after its subsidence. As a prodrome this is im- 
portant. The urine generally contains sugar and formed elements, red and 



ECLAMPSIA. 349 

white corpuscles, as well as casts; that is, there are present symptoms of 
acute congestion of the kidney. 

Diagnosis. — This at a first glance would seem to be simple, but a careless 
diagnosis entails serious mistakes sooner or later. For example, a convulsive 
seizure during pregnancy or the puerperium cannot be positively accepted 
as eclamptic. The pregnant, parturient, or puerperal woman is subject to 
four conditions which must be diagnosticated from eclampsia. These are (i) 
epilepsy, (2) hysteria, (3) apoplexy, and (4) meningitis. Epilepsy is character- 
ized by the history of repeated attacks, and by the presence of urine of normal 
quantity, containing no albumin and no casts (except in intercurrent nephritis). 
Coma, in this condition, is more profound, there is no oedema, and the usual 
aura constitutes the only prodrome. The characteristic sharp cry and sudden 
fall of the epileptic must be remembered. Patients suffering from hysteria are 
generally conscious during the attack, the contractions of the muscles are 
less pronounced, and coma never exists. There is no oedema, and there is excre- 
tion of large amounts of clear and pale urine. These patients cry, laugh, or 
scream. There is often in this affection, also, a history of former attacks. 
Apoplexy rarely occurs in pregnancy. There are no prodromes. Coma quickly 
follows. Convulsions are not present, and there is noticeable paralysis. Its 
occurrence is sudden. Meningitis is a still greater rarity. The spasms, in- 
stead of being general as in eclampsia, are local, and their increase in severity 
occurs very gradually. They are always preceded by rise of temperature. 
The history of this affection is most important in making the diagnosis. When 
in any doubt, the characteristics of the urine, its quantity, the presence of 
albumin, sugar, blood', and casts, should be most carefully ascertained. The 
results of these investigations, together with the clinical picture, should clear 
up the diagnosis with little difficulty. 

Prognosis. — In 10 cases of eclampsia occurring among 2200 cases of labor I 
found the maternal mortality was 2 cases, or 20 per cent. Of the viable chil- 
dren, all lived. Puerperal eclampsia is still a very grave affection. Many statis- 
tics show, even at the present time, a maternal mortality of 30 per cent., while 
that of the child reaches 50 per cent. There is imminent danger of a seizure 
in the pregnant woman who shows marked symptoms of toxemia, albuminuria, 
and the quantity of whose urine is gradually decreasing. The danger becomes 
more pronounced in proportion to the increase of the albumin and the decrease 
of the water excreted in the twenty-four hours. As these conditions are re- 
versed, to a corresponding extent the peril becomes more remote. The amount 
of urea excreted is a more important factor in prognosis than that of albumin, 
as has been clearly shown by Bouchard and Davis. Davis discovered that the 
symptoms of toxemia decrease with the increase of urea. The gravity of the 
prognosis increases in proportion to the early stage of pregnancy at which the 
convulsion occurs. It has been demonstrated by Schauta many times that 
all derangements, ev^en those of renal origin, subside after the child's death; 
thus the prognosis will improve in repeated attacks in proportion to the 
early occurrence of its death. Profuse sweating, especially of early occur- 
rence, is a favorable sign. The prognosis becomes most unfavorable when 
the seizures take place in pregnancy, when they follow one another rapidly, 
when they become gradually more pronounced, and when they have existed 
for an extended period before assistance can be obtained. Mortality has been 
decreased by chloroform treatment in these cases. Briefly, the prognosis is 
favorable when: (1) The attacks are far apart and not severe. (2) The child 
perishes. (3) The patient has conscious intervals between the attacks. (4) The 



350 PATHOLOGICAL PREGNANCY. 

quantity of albumin is small. (5) Decrease of temperature occurs. (6) The 
seizures take place in advanced labor or during the puerperium. Prognosis 
is not favorable when opposite conditions exist. 

The vitality of a child born of an eclamptic mother is below normal, and it 
often dies in the first twenty-four hours. The mother may succumb from ex- 
haustion; cerebral apoplexy due to forcible rupture of the vessels; asphyxia 
caused by spasm of the glottic and respiratory muscles /oedema of the lungs 
or of the brain, following a serous effusion from overcharged capillaries; con- 
gestion of the brain, in which coma is the chief symptom; or cardiac paralysis. 
The last, when taking place during the general convulsion, is followed by instant 
death. The child's death may be due to maternal convulsions and the pres- 
sure resulting therefrom; asphyxia, caused by compression or oedema of the 
placenta, or an extreme amount of carbon dioxide in the blood; or it may 
be by direct poisoning by the toxins in the maternal circulation. 

Treatment. — The best etiological theory of the present day, although it may 
not be correct in all details, is that eclampsia is due to toxemia. Taking this 
for granted, then, the prophylactic treatment of eclampsia is far more im- 
portant than the curative, since it is usually possible to prevent the attack. 
Many prominent American as well as foreign obstetricians hold this opinion. 

The Preventive Treatment. — The pre-eclamptic symptoms comprise a rapid 
pulse, generally accompanied by high arterial tension; anorexia, gastrointestinal 
derangements; mental and physical lassitude; headache; decrease of all the 
excretions, both solid and liquid, either gradual or rapid; that is, just those 
disturbances that might be expected from the introduction or retention in 
the circulation of some toxin. The quantity of urine excreted in twenty- 
four hours is not always to be depended upon as an exact guide to renal 
failure. As has been stated, albuminuria may be wanting before, during, 
and even after an eclamptic convulsion. (See Toxemia of Pregnancy.) 
The eclamptic tendency increases proportionately with the advance of 
pregnancy and the consequent increased fetal metabolism. Besides, it is 
well known that the mortality of the mother decreases gradually from the 
ante-partum to the post-partum condition; that is, it is maximum when 
the onset of eclampsia occurs during pregnancy, diminished during labor, and 
is minimum when the seizure takes place for the first time after the child is 
born. Thus statistics tabulated by Green * show the maternal mortality in 
ante-partum eclampsia to be 46 per cent.; fetal mortality, 69 per cent.; 
in intra-partum eclampsia, maternal mortality, 25 per cent.; fetal mor- 
tality, 25 per cent.; in post-partum eclampsia, mortality of mother 7 per cent. 
There is offered, from the present knowledge of the etiology of puerperal eclamp- 
sia, at least a working hypothesis — namely, the early recognition of the pre- 
eclamptic stage. In addition to the monthly or bi-monthly examination of 
the urine for the detection of albumin, something more is needed, since non- 
albuminuric eclampsia exists in from 9 to 16 per cent, of cases, and it seems 
quite as fatal as albuminuric eclampsia, sometimes more so. In addition to the 
physical signs of decided kidney inadequacy, as an index of impending eclamptic 
seizure, we should watch for the general symptoms of a circulation overcharged 
with poisonous material — high arterial tension, headache, dizziness, gastric dis- 
orders, mental and physical lassitude; and for disturbances of the bowels, liver, 
skin, and lungs, and their failure properly to perform their functions, in order that 
the patient may be intelligently treated. Under these conditions only is the whole 

* Green: "Puerperal Eclampsia; Experience of the Boston Lying-in Hospital in the 
Last Eight Years," " Amer. Jour, of Obstet.," 1893, 28, 18-44. 



ECLAMPSIA. 351 

duty of the physician to the patient accomplished. The following is the line 
of treatment suggested by me for this state: (i) The amount of nitrogenous 
food should be diminished to a minimum. (2) The prodtiction and absorption 
of poisonous materials, in the intestines and body-tissues, should be limited and 
their elimination should be aided by improving the action of (a) the bowels, (b) 
the kidneys, (c) the liver, (d) the skin, and (e) the lungs. (3) The source of the 
fetal metabolic products, and the peripheral irritation in the uterus should, if neces- 
sary, be removed by evacuating that organ. The first indication, reduction of the 
quantity of nitrogenous food, can be best met by an exclusive milk diet, to 
which, as the symptoms improve, fish and white meats may be added. It is 
more agreeable to the patient, and a safer course to pursue, to begin at once 
with an absolute milk diet, than to compromise, and later to institute a strict 
milk diet. An abundant supply of pure air and water must be offered for the 
second indication, that of elimination. To this may be added gentle exercise or 
light calisthenics, or even massage, in some instances. In treating the bowels 
the writer advises the use of daily doses of colocynth and aloes at bedtime, fol- 
lowed by a saline the next morning. For the liver, I find efficacious an occa- 
sional dose of calomel and soda at bedtime, followed in the morning by one of 
the stronger sulphur waters, as Rubinat, Villacabras, or Birmensdorf. Large 
doses of glonoin are excellent to increase diuresis. To encourage the function 
of the skin, the body should be clothed in wool or flannel, massage may be 
used, and, according to the severity of the case, the warm bath, hot bath, 
hot pack, or hot-air bath may be resorted to. A definite diaphoretic-diuretic 
action, together with the additional prompt effect upon the liver and intes- 
tines, is obtained by the following treatment: A tablet composed of calomel, 
digitalis, and squill, each 1 gr. (0.06 gm.), and muriate of pilocarpin, -fa gr. 
(0.003 m g-)> is given. The next morning a full dose of Villacabras water is 
administered. Thus four of the five eliminative processes are urged to per- 
form their functions more energetically. I approve of the use of jaborandi 
in the pre-eclamptic state, provided there is no pronounced cardiac disease, 
although it has been generally abandoned as a diaphoretic during the eclamptic 
seizure. Inhalations of oxygen are beneficial when a sufficient supply of fresh 
air is wanting, and in cases in which exercise cannot be taken. Some prepara- 
tion of iron is indicated, as Basham's mixture, or the tincture of the chloride. 
Each case must be treated individually; no absolutely definite rules can be 
followed; but the preceding suggestions comprise the general hygienic and 
medicinal treatment of the pre-eclamptic state. In certain cases a restricted 
diet and gentle stimulation of the functions of the kidney and intestines are 
sufficient, and the patient may be allowed a certain freedom, even exercise 
in the open air, the skin being protected by wool or flannel. In more severe 
cases of eliminative insufficiency the patient must be kept perfectly quiet 
in bed, allowed, only a strict milk diet, while all of the eliminative organs must 
be stimulated in order to remove the symptoms of impending eclampsia. 
However, it should be thoroughly understood that the milk diet is the corner- 
stone of the preventive treatment of puerperal eclampsia, the hygienic and 
medicinal treatment being only of secondary importance. In a case in which, 
despite an exclusive milk diet and the energetic stimulation of the five elimi- 
native processes, the symptoms and signs of the pre-eclamptic state still per- 
sist, or at any time become urgent, abortion or artificial premature labor is 
indicated. The ideas of those authorities (especially of the British school 
of midwifery) who do not, in the presence of urgent symptoms, approve of 
inducing labor in the pre-eclamptic state are difficult to understand. How- 



352 PATHOLOGICAL PREGNANCY. 

ever, attention must be paid to the arguments that labor induced by the usual 
methods increases reflex excitability and precipitates convulsions; that by 
such methods the patient's fate is sealed before delivery, on account of the 
time necessary to eliminate the barrier of the cervix; and, lastly, that the 
patient's danger is increased by the onset of labor. In reply, it may be stated 
that the methods of terminating the pregnancy advised here need not neces- 
sarily increase reflex excitability, and, should they do so, it is easy to control 
the excitability for the time necessary to attain our ends; that the necessary 
time is generally very short; and, indeed, that at the present time the onset 
of labor and the termination of pregnancy may be practically synchronous, 
and that there is consequently no extended or tedious labor to exert its un- 
favorable reactions upon the patient. Byers * made the objection that, on 
account of the necessary manipulation, induced labor increases the risk of 
sepsis. This, however, should not prevent the modern obstetrician from under- 
taking the operation when he is assured of being surgically clean. Charles, 
of the Liege Maternity, gave statistics at the International Congress of Ob- 
stetrics and Gynecology in 1896 which were greatly in favor of this procedure, 
of induced labor, when prophylaxis fails or the pre-eclamptic symptoms become 
urgent. His table demonstrates that every mother recovered and 75 per 
cent, of the children lived. The writer strongly advises a quick manual dila- 
tation of the os in these cases ; only, however, after the cervical canal is in a 
condition suitable for its safe performance. He would also insist upon a com- 
plete dilatation of the os, before the operator undertakes to deliver the patient. 

The Curative Treatment. — An eclamptic seizure presents a desperate con- 
dition. From various parts of the world the most recent statistics continue 
to estimate the maternal mortality at from 25 to 35 per cent. Rational curative 
treatment of this affection will remain impossible as long as its pathology 
continues obscure. From experience no one treatment can be recommended 
for all cases. No matter what treatment may be pursued, many women recover, 
many die in spite of treatment, while others do well with no treatment at all. 
No one treatment, then, can be advised; each case must be attacked in accord- 
ance with the existing indications. A combined treatment gives better promise 
than a single, for preserving the lives of mother and child, in the event of an 
eclamptic attack. For this combined treatment the three following indications 
are offered: (1) Control the convulsions; (2) eliminate the poison or poisons 
which we presume cause the convulsions; (3) empty the uterus under deep 
anesthesia, by some method that is rapid and that will cause as little injury 
to the patient as possible. These indications, though stated in the order of 
their importance, still may be carried out synchronously. In another class 
of cases the first and second indications should be fulfilled, while the physician 
waits for a suitable moment to undertake the third. The second indication, 
elimination, Logically accompanies the first and third, and should be under- 
taken at the same time with them. 

1. Control of the convulsions. The most effective as well as the safest 
medicinal anti-eclamptics are chloroform, morphin (hypodermatically), vera- 
trum viride, and chloral hydrate, the latter being used alone or in com- 
bination with the bromide of sodium. I prefer chloroform, veratrum viride, 
and chloral, in the order stated. For the last three years I have abandoned 
almost entirely the use of morphin, since it seems to prolong the post-eclamptic 
stupor, while it increases the tendency to death during coma, by its interference 
with the eliminative processes. The most reliable of all agents for immediate 
*Internat. Congress of Obstet. and Gynecology, Geneva, Sept., 1896. 



ECLAMPSIA. 353 

control of the convulsive attacks is chloroform. Veratrum viride, in efficiency, 
stands second only to chloroform. With the pulse strong as well as rapid, 
it offers the most certain means at our command for temporarily, and even 
permanently, controlling the spasms. With a weak pulse, morphin hypo- 
dermatically, inhalations of chloroform, and chloral administered per rectum, 
together with stimulation, if necessary, may be used instead. The pulse-rate 
is diminished by veratrum viride, and convulsions are almost unknown when 
the pulse-rate is 60 or under; the temperature also is reduced, and the rigidity 
of the cervical rings is relaxed; diaphoresis and diuresis are promptly effected; 
so that, by the use of this drug, our first indication, the control of the convulsions, 
is fulfilled as well as the third, the elimination of an unknown toxin. The initial 
dose of the fluid extract of veratrum viride, given subcutaneously, should 
be generally from 10 to 20 minims (0.6 to 1.2 gm.); an additional 10 minims 
(0.6 gm.) may be administered by the same method every succeeding half- 
hour, till the pulse continues below 60 to the minute. While under the influence 
of the veratrum, the patient should be kept in a recumbent position. Tumul- 
tuous heart-action will probably supervene when the erect position is assumed. 
Whiskey or morphin will easily control vomiting and collapse, if they occur. 
Rapid evacuation of the uterus is the final resort for the control of the con- 
vulsions. However, it might be stated that ice-bags to the back of the head 
and neck have a decided effect in controlling and in preventing convulsive 
seizures. 

2. Elimination of the poison or poisons which are presumed to cause the con- 
vulsions. The following means may be advised to eliminate the poisonous 
material from the blood and tissues. Not only one, but all of the eliminative 
organs of the body should be brought into play, and the following indication 
in eclamptic treatment should be carried out along with the two previously 
described methods. As early and prompt catharsis as possible should be ob- 
tained, by means of croton oil, compound jalap powder, or calomel followed 
by salines, and high enemata of magnesium sulphate. The writer prefers 
to treat the comatose condition, or post-eclamptic stupor of the affection, by 
repeated doses of concentrated solutions of magnesium sulphate or Villacabras 
water, administered by means of a long rectal tube, high up in the descending 
colon. Hypodermatic injections of the sulphate of magnesium have been 
demonstrated to be too slow and ineffective to accomplish any good. Dry 
or wet cups over the kidneys, followed by hot fomentations, is an excellent 
method of causing diuresis. Glonoin is invaluable as a diuretic and anti- 
eclamptic, the latter indication being fulfilled by diminished arterial tension. 
Veratrum viride stands next in order of efficiency. The objects of its admin- 
istration, at this time, are similar to those in the pre-eclamptic condition. The 
hot-air bath or the hot pack encourages diaphoresis, the writer preferring the 
former. On account of the danger of pulmonary and glottis oedema, incident to 
the use of pilocarpin as a diaphoretic, in the existence of an eclamptic seizure, 
its use should not be countenanced. It is a measure of doubtful value to extract 
large quantities of poisonous liquids, in the form of blood or serum, by the 
methods of venesection, catharsis, diaphoresis, diuresis, and replacing the same 
by intravenous, stomachic, rectal, or hypodermatic means, by which a cleansing 
or disintoxication of the blood and tissues is obtained. Moreover, very satis- 
factory results have been obtained by extended irrigation of the lower bowel, 
using either decinormal saline solution or sterile water, by means of a long, single 
or return-flow tube. Collapse attended by a small compressible pulse, as in 
the same conditions under other circumstances, is effectively treated by the 
23 



354 PATHOLOGICAL PREGNANCY. 

introduction into the blood of a decinormal saline solution. Some authority 
advocate the hourly subcutaneous injections of ether as a diuretic. Abunda 
administration of oxygen is invaluable as a general stimulant, to assist t 
eliminative function of the lungs, and to sustain life in post-eclamptic stupe 
or coma. Alcohol is often a necessary stimulant, both during and after a: 
eclamptic seizure, and strychnin has proved effective in the post-partun. 
condition, and with impending collapse; although, reasoning from a physio- 
logical standpoint, it would seem to be contraindicated. 

3. Empty the uterus under deep anesthesia, by some method that is rapid ana 
that will cause as little injury to the woman as possible. Many cases that could by 
prompt and intelligent treatment be saved will probably succumb if the teach- 
ings of Charpentier, of France, and Winckel, of Germany, are followed — nameh 
that the eclamptic uterus should not be disturbed till after the os is ful. / 
dilated, since the irritation of inducing labor, or artificially dilating the cervi: 
brings on convulsive seizures. Careful observations seem to show that danger 
is essentially passed, in some 90 per cent, of cases, immediately after the uterus has 
been emptied, if this is accomplished early in the seizure. The convulsions do 
not always cease by this method, but they become less dangerous, and the case is 
converted to one of post-partum eclampsia, in which, as has been stated, the 
mortality is only 7 per cent. Although there is scarcely an authority of the 
present day who absolutely rejects local interference, in the existence of ante- 
partum or intra-partum eclampsia, still there is a wide difference among authori- 
ties with regard to the extent to which such interference shall be pursued. Char- 
pentier, in 1892, after having exhaustively analyzed 454 cases of eclampsia, and 
again, in 1896, after further careful observation, comes to the conclusion that: 

(1) Labor should be waited for, and terminated naturally whenever possible; 

(2) induced labor should be reserved for exceptional cases in which medicinal 
treatment has entirely failed; (3) interference should be delayed until the 
cervix is dilated or dilatable, so as to avoid danger to the mother; that in eclamp- 
sia Caesarean section, manual dilatation of the cervix, and especially deep inci- 
sions of the cervix, are absolutely unjustifiable. However, it seems from the 
reports of the International Congress at Geneva, September, 1896, and from the 
literature of the last five years, that the best authorities are in favor of emptying 
the uterus as quickly as possible, in cases of eclampsia, whether the attack takes 
place before or during labor, although the opinion as to the method to be 
employed varies widely. Nevertheless, in the second stage of labor, after securing 
dilatation, all are agreed that there is indication for the immediate emptying of 
the uterus, and this operation should be promptly performed. This is accom- 
plished with no additional danger to mother or child. In pregnancy and the 
first stage of labor, the barrier offered to rapid delivery is the undilated cervix, 
and it is just here that obstetricians hold such different opinions as to the best 
plan of procedure. Expectant or palliative treatment will almost surely be 
followed by death of the child, and about one-third of the mothers succumb. 
But if the uterus is promptly evacuated by suitable surgical means, the child's 
life is preserved and the mother is practically subjected to no danger. During 
pregnancy and early labor four methods are suggested for quickly emptying the 
uterus: (1) Csesarean section; (2) mechanical dilatation of the cervix (various 
methods); (3) deep incisions, which at once completely remove the barrier of 
the cervix; (4) combined mechanical dilatation and deep cervical incisions. 
A high mortality (36.26 per cent., according to the figures of Charpentier) 
attends the first method — Csesarean section — for the relief of eclampsia; many 
objections, moreover, are offered to its employment; atony and hemorrhage of 



ECLAMPSIA. 355 

\e uterus; irritation caused by the uterine and abdominal scars, as well as 
it coincident with the curative peritonitis about the uterine sutures, all of 
ich should be shunned as exciting causes of future eclamptic attacks. The 

opular method of the present day seems to be mechanical dilatation of the 

ervix, and the prompt extraction of the fetus. This method is safe and effec- 
ive when properly performed. However, the safe performance of this method 
will demand from forty minutes to an hour and a half before dilatation is well 
idvanced. Certain cervical conditions, even with this allowance of time, will 
not yield to manual dilatation, or else entail lacerations of the lower uterine 
segment. By the third method of delivery, that of deep incision of the cervix, is 
presented a surgical means for emptying the uterus in from five to ten minutes, 

• condition that the supravaginal portion of the cervix has disappeared, either 
itself or by the application of appropriate measures. The fourth method 

Surprises a combination of the second and third, and is suitable for cases in 
vvhich the supravaginal portion of the cervix has not disappeared, and prompt 
emptying of the uterus is indicated. In this method the os is mechanically 
dilated until the internal os has disappeared, when the dilatation is at once 
completed by means of the incisions. There are few statistics to offer con- 
cerning the results of the third method and its modification, the fourth, on 
account of their comparatively recent introduction. In general, the indications 
will be fulfilled by a prompt manual dilatation of the os, followed by extraction of 
the fetus; however, unless this can be expertly carried out, with an intelligent 
understanding of the mechanism of dilatation, particularly in primiparae, more 
favorable results will be attained by a strictly expectant treatment. Although the 
mortality is greater in multiparas, nevertheless, puerperal eclampsia is unfortu- 
nately four times more frequent in primiparae. The cervix uteri consists of 
muscle-fibers, both constricting and dilating, and while it is known that labor is 
generally induced by the first convulsions, nevertheless the supervening asphyxia 
has a decided constricting influence upon the body of the uterus and the cervix, 
which is most definitely exemplified at the internal os. Consequently, there will 
be imminent danger of uterine rupture in any method of rapid manual dilata- 
tion of the os undertaken before the internal os has at least partly disappeared. 
This fact particularly concerns primiparae, in whom the supravaginal portion of 
the cervix persists late in pregnancy, and even up to the beginning of labor 
Uterine rupture and death have not infrequently followed the careless perform- 
ance of rapid manual dilatation of the os, especially in eclampsia; and undue 
shock has been caused by dragging a fetus through an imperfectly dilated os, 
not to speak of the death of the child. Hence the greatest care in this manipula- 
tion is demanded. In case of placenta praevia, the lower uterine segment and 
the cervix are made more easily dilatable by the hemorrhage and supervening 
anemia. The reverse is true in eclampsia, as has been before suggested. Con- 
sequently in eclamptic attacks, in which the internal os has been elevated to the 
body of the uterus, and there is persistence of a rigid and tense external os, espe- 
cially in primiparae, and when there is pressing need of immediate termination of 
labor, I advise four clean incisions, reaching from the border of the os to 
the utero-vaginal junction, in order to preserve the patient from the more 
imminent dangers of rapid manual dilatation. Secondly, great care should be 
taken not to extract the fetus prematurely, before full dilatation has been 
attained and the external os paralyzed. I have seen cases of premature 
extraction, under these circumstances, which have been followed by many unnec- 
essary and dangerous lacerations of the lower uterine segment, and by an in- 
creased mortality of both mother and child. 



356 



PATHOLOGICAL PREGNANCY. 



Although I have the strongest faith in the efficiency of an immediate removal 
of fetal metabolism and irritation, in order not only to control but to cure the 
eclamptic attack, I must protest, first, against the careless use of the term accouche- 
ment force as applied to the rapid, scientific, and intelligent evacuation of the 
uterus; and, secondly, against the thoughtless recommendation of this method 
as being the best, if not the only one at our command, for controlling 
eclamptic convulsions, without giving due consideration to the condition of 

the cervical barrier. 

Accouchement force comprises 
to-day three operations — namely, 
(i) the complete instrumental or 
manual dilatation of the cervical 
canal, followed by (2) either com- 
bined or direct version, or the 
application of the forceps, and 
(3) the immediate extraction of 
the child. Accouchement force, as 
understood by the older obstet- 
rical authorities, was often quite 
a different and a graver opera- 
tion, for there was often no atten- 
tion paid to the canal of the cer- 
vix, and it too frequently meant 
the thrusting of the hand, or the 
use of forceps, through a cervical 
canal which was only partly di- 
lated, and the prompt extraction 
of the child through this con- 
tracted os (Fig. 474)- The fre- 
quency of accidents in the extrac- 
tion of the fetus, that are per- 
petually recorded, seems to show 
that the old ideas still persist. 
Patients are continually brought 
to the hospitals giving evidence 
of the fact that the operator has 
failed to perform the first con- 
dition of the operation — namely, 
complete dilatation. Not un- 
commonly are cases brought in 
with a podalic version or extrac- 
tion partly performed, because 
the operator was attempting his manipulations before the os was completely 
dilated. Rupture of the uterus also occurs from the same cause. Fig. 
1 09 1 shows the results of a premature extraction before the os had been 
perfectly dilated. In cases of this kind, the external os being rigid and 
incompletely dilated, and tightly hugging the fetus under the arm-pits, the 
gradual extraction of the arms, and later of the head, through this constricting 
ring will consume considerable time, and not only result in the death of the child, 
but cause dangerous, if not fatal, rupture of the lower uterine segment. The dan- 
gers of extraction, whether performed by means of forceps or of version, may be 
decreased to a minimum, for both mother and child, if perfect dilatation or dis- 



/nfernalos 



Ejrfernal ' os. 




£kuM>, 



Bectufrv 



Fig. 481. — Frozen Section of the Uterus of a 
multigravida at the thirty-fourth week, 
Who Died before Any Labor Pains Occurred. 

Note the length of the cervical canal and the 
closed condition of the internal os. — {Leopold.) 



DISEASES OF THE URINARY TRACT. 357 

appearance of the external os is attained, as is shown in Fig. 1093, or even if the 
os is paralyzed, as is exemplified in Fig. 1090. It is well for the patient suffering 
from an eclamptic seizure that the frequency of the convulsions increases propor- 
tionately with the progress of pregnancy, and, indeed with the increase of fetal 
metabolism. As already stated, it is unfortunate that the eclamptic seizure is four 
times more frequent in primiparae than in multiparas, and in primiparae the persist- 
ence of the supravaginal part of the cervix, even to late gestation, and of a rigid 
and unrelaxing os, necessitates the use of preliminary and temporizing methods 
before a rapid dilatation of the os and subsequent extraction of the fetus can 
be safely performed. In these cases which are so critical, after the institution of 
measures preparatory to a rapid dilatation and evacuation of the uterus and 
waiting for them to culminate, so that at least the cervical canal may have 
been rendered somewhat relaxed, even if the internal os has not partly dis- 
appeared, my experience has proved veratrum viride invaluable, for the 
preservation of life, on account of the various characteristics of the drug, 
before described. 



XI. DISEASES OF THE URINARY TRACT. 

1. Passive Congestion of the Kidney. 2. Acute Nephritis. 3. Chronic Nephritis. 4. Floating 
Kidney ; Tumors of the Kidney. 5. Pyelonephritis. 6. Hydronephrosis. 7. Renal 
Calculi. 8. Renal Insufficiency, and Toxemia, g. Vesical Irritation. 10. Cystitis. 
11. Incontinence of Urine. 12. Urinary Retention. 13. Vesical Hemorrhoids. 14. Vesi- 
cal Calculi. 13. Cystocele. 16. Vesical Neoplasms and Traumatism. 17. Albumin- 
uria. 18. Polyuria, ig. Peptonuria. 20. Hematuria. 21. Glycosuria. 22. Lipuria 
and Chyluria. 23. Acetonuria. 24. Urinary Sediments of Pregnancy. 

i. Passive Congestion of the Kidney. — This condition, when due to any 
obstruction of the return flow of venous blood, may, of course, complicate 
pregnancy; but the term is usually applied to a supposed consequence of the 
pressure of the gravid uterus itself. Anemia of the kidney: But since the in- 
creased intraabdominal pressure of pregnancy affects the renal arteries as well 
as the veins, the tendency is naturally toward an anemic rather than a passively 
congested kidney. This anemia is assumed to be the forerunner of albuminuria 
and fatty degeneration; or, in other words, is the first step in the formation 
of the so-called kidney of pregnancy. Its existence is naturally associated with 
the latter part of pregnancy, after the gravid uterus has attained a certain size; 
but some authors see in anemia of the kidney a reflex element, believing that 
compression of the nerves in the uterus causes a lowering of blood-pressure in 
the kidney. Pregnancy-kidney : This important condition is considered under 
toxemia of pregnancy, eclampsia, and albuminuria. It is enough to state here 
that it is essentially a fatty degeneration or infiltration of the renal epithelia 
which varies much in degree, but which with very few exceptions undergoes 
complete resolution after delivery. There is more or less tendency toward 
recurrence at subsequent pregnancies. 

2. Acute Nephritis. — Acute nephritis may develop during pregnancy as a 
purely accidental complication, differing in nowise as to etiology, symptoms, 
etc., from the same affection as it occurs in the non-gravid. The fact that such 
a condition is to be construed for practical purposes as a severe form of preg- 
nancy-kidney — with which, however, it has no known relationship — makes it 
necessary to state but little under a separate heading. Acute nephritis is 
attended with greater local and general disturbance, and its prognosis as a dis- 
ease per se is less favorable. It tends to cause uremia, while in pregnancy- 



358 PATHOLOGICAL PREGNANCY. 

kidney the toxic state is believed to precede the renal lesion. In cases in which 
a differential diagnosis cannot be made between acute intercurrent nephritis and 
pregnancy-kidney, it will be difficult to decide whether the toxic state is uremic 
or eclamptic. Recent studies in cryoscopy show a difference in the blood in 
these conditions; so that the differentiation should be rendered absolute. 
Finally, acute nephritis, although it might possibly end in resolution in time, 
would have no necessary tendency to terminate with delivery, and would in 
most cases result in chronic nephritis, a termination unusual — and according 
to some, unknown — in pregnancy-kidney. 

3. Chronic Nephritis. — Chronic nephritis sometimes becomes apparent after 
conception in the absence of any previous suspicion of the disease. If a woman 
show the evidences of renal lesion very soon after impregnation, the inference is 
that the affection is of considerable duration. It happens occasionally that a 
woman with chronic nephritis becomes pregnant when fully aware of her condi- 
tion. The influence of gravidity is usually serious, and becomes more marked for 
each successive pregnancy. The mother may be variously affected. She may 
die as the result of labor if the latter is severe in character or complicated by 
operative intervention. Or the confinement may be uneventful, but the disease 
may undergo a severe, perhaps fatal, exacerbation during the puerperium. It 
is known that these patients readily become septic, and that very slight trauma- 
tisms may become infected. In regard to the action of chronic Bright 's disease 
upon the character of the pregnancy and fetus, there are no notable differences 
in comparison with pregnancy-kidney. While opinion is divided as to the ad- 
visability of interrupting pregnancy in pregnancy-kidney and in acute nephritis, 
authors agree that intervention of this sort is more justifiable in chronic neph- 
ritis. The remarkable infrequency of eclampsia in chronic nephritis of preg- 
nancy is an argument in favor of the distinction between uremia and the toxemia 
of pregnancy. 

4. Floating Kidney ; Tumors of the Kidney. — These conditions very seldom 
complicate pregnancy and labor. The pressure of the gravid uterus, as a rule, 
suffices to keep a floating kidney in place for the time being, and the chief danger 
from this abnormality is during and after the puerperium, when it may become 
aggravated. If the displacement is congenital, or if it occurs suddenly during 
labor, the kidney may enter the pelvis and become incarcerated. The pedicle of 
an ordinary floating kidney may become twisted, and the consequence of such an 
action may include interruption of pregnancy. 

5. Pyelonephritis. — This condition was formerly unrecognized, having been 
confounded with cystitis. In 1889 Kruse * first called the attention of ob- 
stetricians to this complication, and in 1892 Reblaud published a monographic 
study of the subject. Frequency: Pyelonephritis of pregnancy is far from rare. 
According to Vinay, at least one case occurs annually, on an average, in the 
Hotel-Dieu Maternity, Paris. Etiology: This is entirely obscure. Compression 
of the ureters, especially the right, by the gravid uterus will not account for the 
lesion. Vinay f and Reblaud both accuse Bacillus coir of active responsibility, the 
latter even holding that it gains access to the urinary tract by direct propagation 
through the intestine. In support of this contention Bue claims that purgation 
aborts pyelonephritis. Symptoms: The disease may make its appearance at any 
period after the fourth month. The symptoms, while obscure, are usually those 
which characterize a severe acute disease, including a chill, high temperature, 
malaise, etc. Pyuria is present, associated with albuminuria. Diagnosis: This 
is made by exclusion of cystitis. There is induced tenderness over the kidneys. 

* Inaug. Dissert., Wiirzburg. f " L'Obstetrique," May 15, i8qq. 



DISEASES OF THE URINARY TRACT. 359 

Prognosis: The disease persists until pregnancy is terminated. It may recur 
with successive pregnancies. Statistics are rare. Treatment: The indications 
are rest in bed; sedation (hypodermatics of morphin), milk diet and intestinal 
antisepsis. Vinay recommends benzo-naphthol for this purpose. The disease 
does not appear to be severe enough to require the induction of abortion. 

Pyelitis is very rare during pregnancy, being far more common in the puer- 
perium. 

6. Hydronephrosis. — This affection may occur as a result of pressure on the 
ureters by a uterus bound down by adhesions or by twisting of the pedicle of a 
dislocated kidney. The uterus or kidney should be replaced and held in position 
if possible. Interruption of pregnancy usually occurs. 

7. Renal Calculi. — Renal colic is rare in pregnant women because of its in- 
frequent occurrence in the female sex in general. The few published cases are 
probably simply coincidences and the sole interest in considering the subject in 
this connection is the simulation of labor pains by the colic. Diagnosis should 
not be difficult, as the uterus should be found quiescent and the character of the 
pain should cause suspicion of its nature. In cases in which renal calculi have 
been passed after delivery anxiety may be caused through fear of septic peri- 
tonitis. The pulse of the latter, however, should be somewhat characteristic, 
the initial chill and rise of temperature being much more pronounced and the 
painful area more extensive. The treatment of the affection differs in nowise 
from that in the non-pregnant. 

8. Renal Insufficiency. — See Toxemia of Pregnancy. 

9. Vesical Irritation. — This must not be confounded with cystitis, incon- 
tinence, or retention, although some of these conditions may occur side by side. 
It may be described as an almost physiological reaction on the part of the 
bladder toward the irritation of the pregnant uterus. The organ is compressed 
between the symphysis in front and the gravid uterus behind. It is an affection 
most complained of in the early months of pregnancy and in primigravidae, and 
tends to disappear about the fourth month of pregnancy, but often returns in the 
last fortnight. 

Symptoms. — The affection is a dysuria. There is a frequent desire to 
urinate, with pain and scalding. The symptoms resemble those of cystitis but 
are less severe. The distress is removed if the patient takes the recumbent pos- 
ture for the time being. The bladder is usually hypersensitive. In case of 
malposition of the uterus the pressure is usually directed against the neck of the 
bladder, and vesical tenesmus results. If the vesical neck be forced against the 
upper border of the symphysis pubis, there may be retention of urine (page 360). 
This may cause incontinence or the urine may be completely retained and the 
bladder will be overdistended. In this condition, if labor supervenes, rupture of 
the bladder may take place, on account of the decrease of abdominal space 
caused by the retraction of the walls. Cystitis commonly follows overdistention. 
Abnormal presentations and positions of the fetus cause irritability of the 
bladder in the latter months of pregnancy. There is either extreme pressure on 
the bladder or this organ is pushed out of place. The fetus should be replaced 
in normal position, which can be accomplished only by external manipulation. 

Treatment. — The measures for relief are those employed in vesical irritation 
in the non-pregnant, or as in cystitis, to be mentioned later (rest, dorsal decu- 
bitus, baths, anodynes, etc.). Catheterization should be avoided unless abso- 
lutely demanded. A normal presentation of the fetus should be secured if 
possible by external manipulation, and an abdomiral binder (Figs. 233 and 
234) used, which will relieve the bladder of fetal pressure. I have found the 



360 PATHOLOGICAL PREGNANCY. 

modified knee-chest posture (Part X), used twice daily, of great benefit in 
obtaining relief. 

10. Cystitis. — Cystitis of pregnancy is not a rare disease. 

Etiology. — It may originate from some of the minor urinary troubles develop- 
ing early in pregnancy, such as retention due to retroversion. The actual deter- 
mining cause is bacterial, and a number of germs are known to give rise to the 
disease, including Bacillus coli and Staphylococcus pyogenes. These germs appear 
to be unable to infect the normal bladder. Gonococcus cystitis is rarely seen in 
pregnancy. Cystitis arises either through importation of germs by the catheter 
or by their spontaneous migration from the vestibule along the urethra. 

Symptoms. — These consist chiefly in increased frequency of micturition and 
more or less scalding with tenesmus at the close of the act, at which time a 
blood-clot maybe expelled. Much more depends upon the character of the 
urine, which necessarily contains some pus, though the fluid may be clear and of 
acid reaction. Such a urine, upon standing, deposits a heavy sediment consist- 
ing of pus-corpuscles. The type of cystitis which follows upon the irritable 
bladder of early pregnancy is always mild; it may be readily overlooked and 
mistaken for simple urinary irritation unless the urine is carefully tested. On 
the other hand, the cystitis of retention is severe and aggravates the already 
existing state of affairs. The retained urine may readily decompose, the pus 
being transformed thereby into a ropy mass. The combination of retention 
with cystitis has been known to produce abortion. The disease tends to improve 
after delivery, but sometimes persists. In some women cystitis tends to recur 
with each pregnancy. 

Treatment. — Rest and avoidance of exposure are the first considerations. 
Hence, in winter patients had better be confined to bed. The diet should be 
extremely simple, consisting chiefly of clear soups, green vegetables, and farina- 
ceous articles. Alkaline mineral waters should be taken freely. Any diuretic 
infusion may be prescribed, with the additions of sandal-wood in capsules or 
salol. Poultices should be placed over the hypogastrium and anodyne supposi- 
tories may be necessary in severe cases. 

ii. Incontinence of Urine. — True incontinence is rare in pregnancy, al- 
though it is by no means unknown in the later months. It should not be con- 
founded with the ordinary vesical irritability, which is almost inevitable, nor 
with the dribbling which accompanies retention. Causes: The principal cause 
is the encroachment on the bladder of the more dependent portions of the fetus 
during the last weeks of pregnancy. Much depends upon the form and site of 
the bladder in these cases. If the fetus press fairly upon it, any sudden move- 
ment of the diaphragm, as in laughing, coughing, etc., could readily cause the 
emptying of the viscus. In other cases the ascent of the uterus during pregnancy 
may draw the neck of the bladder out of the natural position and relations. The 
constant escape of urine may give rise to excoriations of the vulva and thighs. 
An abdominal bandage will usually relieve this condition (Figs. 233 and 234). 

12. Urinary Retention. — This is conceded to be the most prevalent of all the 
urinary anomalies of pregnancy, owing, perhaps, to the number of types which 
the condition assumes. These are as follows: (1) Retention at the onset of 
pregnancy. The rationale of this is obscure. Some authorities attribute it to 
reflex spasm of the vesical neck. (2) Retention in the course of pregnancy. 
This is due almost exclusively to retroversion of the pregnant uterus, and 
begins at the third or fourth month. (3) Retention toward the close of preg- 
nancy. This is held to be the result of the direct compression of the urethra and 
bladder by the fetal head. 



DISEASES OF THE URINARY TRACT. 361 

Symptoms. — These are self-evident — the urinary tumor and the failure to 
pass water beyond a mere dribbling. This dribbling saves the patient in most 
cases from the accidents of complete retention. If dribbling does not occur 
spontaneously, the patient is still able to get relief by efforts at bearing-down. 
There is naturally much dysuria and reflected pain, while in some instances there 
is a systemic reaction, including fever, anxiety, restlessness, and anasarca. If the 
case is left to itself the bladder gradually distends until it assumes a prodigious 
volume. The use of the catheter is quite likely to lead to infection and cystitis. 
The diagnosis is readily established by palpation and the catheter. The drib- 
bling of retention should not be confounded with true incontinence. The 
prognosis depends upon the character of the relief afforded by the use of the 
catheter and by attempts to remove the causal indication. Treatment: The 
prompt and repeated use of the catheter will insure the patient against the 
immediate unfavorable results of retention. This is offset somewhat by the 
dangers of catheterization. It may be necessary to introduce the instrument in 
the genupectoral position. Glass is the best material for the catheter (Part X). 

13. Vesical Hemorrhoids. — These, like other local pelvic varicosities occur- 
ring during pregnancy, are the result of the general pelvic congestion, and 
usually first draw attention to the condition on the occurrence of rupture and 
consequent hematuria. The condition can only be suspected until cystoscopic 
examination be made. 

14. Vesical Calculi. — Vesical calculi have caused vesico-vaginal fistula dur- 
ing labor and a case is recorded in which a stone was found large enough to 
obstruct delivery.* The induction of labor during the last month of pregnancy 
may be demanded; this late date being chosen in order that the prognosis for 
the child may be rendered as favorable as possible. 

15. Cystocele. — This may cause a pouching of the anterior vaginal wall, the 
tumor even passing through the vulva. It has been mistaken for the amniotic 
sac and punctured. For diagnosis a catheter may be passed into the cystocele 
and palpated by vaginal touch. For treatment, after the bladder is evacuated, 
the anterior vaginal wall should be pushed up in order that pressure by the head 
may be avoided. 

16. Vesical Neoplasms and Traumatisms. — Carcinoma may occur and be 
secondary to carcinoma of the cervix. Vesical irritation and hematuria are 
among the symptoms. 

17. Albuminuria. — The subject of albuminuria in the gravid is an extensive 
one, which is discussed freely under toxemia of pregnancy, eclampsia, etc. It 
merits some independent consideration as well. Occurring in the first half of 
pregnancy it must be regarded as of toxic origin, or as suggestive of hepatic 
insufficiency or renal disease. The so-called functional albuminuria — which 
is now believed to depend largely upon gastric insufficiency — may be present 
before conception; but von Rosthorn (Winckel's "Handbuch," 1903) assures 
us that this condition never becomes aggravated by pregnancy, and that it is 
not necessary to dissuade women with this anomaly from marriage and con- 
ception. 

True albuminuria of pregnancy begins, as a rule, not earlier than the twenty- 
fifth week; and it is of such common occurrence that some recent authors regard 
it as practically the rule. Once believed to be much more common in primi- 
gravidae, it is now thought to occur irrespective of parity. It is probable that 
a small amount of albumin in the urine may be accounted for by circulatory 
disturbances alone, and that to be considered evidence of a toxic state, album- 
* Dakin: "Handbook of Midwifery." page 460. 



362 PATHOLOGICAL PREGNANCY. 

inuria must be associated with other phenomena. When the amount is con- 
siderable, or when it steadily increases from small beginnings, it naturally sug- 
gests both a toxic state and a renal lesion. It by no means follows that the trace 
of albumin so often found comes directly from the blood, for it may simply be 
derived from the epithelia and leucocytes which make their appearance in the 
urine in increasing numbers late in pregnancy. Naturally only traces could be 
accounted for in this manner. 

The fact should be emphasized that waste of albumin is not without signi- 
ficance in pregnancy. Women who pass through this condition without pre- 
judice to themselves despite extensive leakage of albumin have long been known 
to present peculiarities affecting the fetus. Thus such women show a distinct 
tendency to abortion and premature delivery; and while the fetus shows sub- 
development the placenta is increased in size and shows such peculiarities as 
to be termed the "albuminuric placenta." This subject needs to be studied 
anew, for it is possible that a certain phase of endometritis gravidarum may 
account for the entire condition. 

18. Polyuria. — Owing to increased tissue change, a moderate increase of the 
urinary secretion always occurs during pregnancy. Occasionally the increase 
is excessive. Cases are recorded in which 200 or more ounces (6 liters) in a 
day were passed. The urine is usually normal in character except for a low 
specific gravity. The patient suffers from thirst and the annoyance caused by 
frequent urination. Treatment adapted to cause decrease in the flow of urine is 
not advisable. 

19. Peptonuria. — This is sometimes caused by fetal death and the absorption 
of proteids (page 304). In other cases no assignable cause can be found. 

20. Hematuria. — This is usually due to vesical hemorrhoids, but may occur 
from other affections of the bladder and kidneys, as acute nephritis or cystitis, 
calculi, neoplasms, or traumatisms of the bladder. For treatment the pelvic 
congestion should be relieved by avoiding constipation and tight clothing. In- 
jections of astringent solutions may be tried in bad cases if the symptoms point 
to the bladder as the seat of the trouble. 

21. Glycosuria. — The existence of glycosuria in pregnancy and the puer- 
perium has been known for many years, and in 1877 it was ascertained that 
puerperal glycosuria was a lactosuria, and thereby related in some manner to 
the secretion of milk. The glucose which may sometimes appear to indicate a 
toxemia should not be regarded as necessarily pathological, for if the tests are 
of sufficient delicacy this substance may be found in nearly all urine, and must, 
under these circumstances, be regarded as purely dietetic. This fact has been 
made the basis of Schenck's method of controlling sex of the offspring; since if 
the normal trace of sugar cannot be made to disappear by diet, the infant will 
probably be a female (see page 90). Regarding the high degrees of glycosuria 
and true diabetes, since these conditions may develop during pregnancy or 
be present throughout it, the outlook is much the same as in operative 
surgery, and the greater the degree of glycosuria, the worse the prognosis. 
Statistics appear to show that labors in these women are quite apt to end unfavor- 
ably in one or another way.* The fact that diabetes has been known to set in 
during pregnancy and disappear spontaneously after delivery would seem to 
connect such a phenomenon with the special toxemia of pregnancy. Women 
who have thus recovered have gone through subsequent pregnancies without 
reappearance of the disease. Other records indicate that a diabetes lighted up 
in pregnancy may remain permanent. When a diabetic woman becomes 

* Matthews Duncan: "Trans. Obstet. Soc. London," 1882. 



DISEASES OF THE URINARY TRACT. 363 

pregnant, her disease usually takes a turn for the worse, with a tendency to 
improve temporarily after confinement. According to Lecorche, true diabetics 
who become pregnant usually succumb to the disease within a short time after 
delivery. 

22. Lipuria and Chyluria. — These conditions are occasionally noticed. The 
former is due to the general increase in adipose tissue throughout the body. 
They are of no special clinical importance. 

23. Acetonuria. — The metabolic changes incident to pregnancy would 
naturally direct one's attention to the index of metabolism, the urine. The 
significance of acetonuria in general not being well understood, such an investi- 
gation as that undertaken by Max Stoltz,* in "Acetonuria in Pregnancy, Child- 
birth, and Puerperium," is highly welcome. He finds that a slight acetonuria 
which is physiologically found in pregnant women is not constant but is quite 
variable. Increased acetonuria is frequently found in the course of preg- 
nancy, lasting for one, two, or three days, without any symptoms of patho- 
logical causes. In the majority of cases during child-birth there is increased 
acetonuria. The longer the labor lasts, the more frequently does acetonuria 
occur and the more abundant it is. In primiparae it is more constant and greater 
than in multiparas. During the first three days of the puerperium, occasionally 
during the first four days, it is considerably increased. Less often it appears 
greatly increased later in the puerperium. The increased acetonuria of the 
puerperium is, as a rule, closely connected with same condition during parturi- 
tion. The influence of the establishment and the continuance of lactation upon 
this condition requires further investigation. Increased acetonuria in pregnancy 
and parturition is worthless as an index of the death of the fetus. It is a phy- 
siological manifestation, without any pathological significance or cause. It 
is explained by the alteration in fat metabolism during pregnancy and the suc- 
ceeding states, and, corresponding to it, is of irregular and transitory duration. 

24. Urinary Sediments of Pregnancy. — It is now known that abnormal 
deposits occur in the urine of the gravida in the latter half of pregnancy in not 
less than 97 per cent, of all cases. (Fischer, "Arch. f. Gynekol.," xliv.) This 
appears to result largely from circulatory disturbances which are inseparable 
from direct and indirect pressure from the enlarging uterus. There is more 
or less desquamation along the entire urinary tract, as shown by catherisation 
of the ureters. In the renal epithelia fat droplets may sometimes be seen. 
There is always a leucocytosis in the urine of the gravid, and the corpuscles 
may proceed from the bladder or kidney; in the latter case being accompanied 
by albuminuria. Erythrocytes and hematoidin crystals are sometimes encoun- 
tered, and are thought to proceed almost wholly from the ureters unless, of 
course, nephritis is present. Finally it is not uncommon to find hyaline casts 
(25 per cent., Fischer), which are by no means necessarily associated with al- 
buminuria. These cylinders are sometimes covered in part by renal epithelial 
leucocytes, or erythrocytes. Granular casts are present but rarely and are 
always accompanied by albuminuria. 

These sediments are present at first but sparsely, but increase regularly 
toward term. During labor they attain a maximum, and erythrocytes are 
then invariably present in large numbers. 

* "Archiv f. Gyn.," Feb., 1902. 



364 PATHOLOGICAL PREGNANCY. 



XII. DISEASES OF THE ALIMENTARY TRACT. 

I. Gingivitis. 2. Dental Caries. 3. Oral Sepsis. 4. Salivation or Ptyalism. 5. Anorexia. 
6. Nausea and Vomiting 7. Persistent Vomiting; Hyperemesis Gravidarum. 8. Mal- 
aria; Longings. Q. Gastric and Intestinal Indigestion. 10. Consumption. 11. Diar- 
rhea. 12. Hemorrhoids. 13. Jaundice; Icterus Gravidarum. 

i. Gingivitis. — An inflammation of the gums due to the blood-changes of 
pregnancy not infrequently occurs during gestation. It usually subsides after the 
birth of the child, though it may continue throughout lactation. This affec- 
tion is generally coincident with salivation, although it may occur alone, 
and is more frequently seen in multigravidae than in primigravidas. The gums 
are swollen and tender and bleed at the slightest touch; they are retracted, 
leaving the necks of the teeth exposed to all the secretions of the mouth, and as 
these are frequently very acid, their effect upon the teeth is deleterious. The 
latter are apt to become loosened, making mastication difficult as well as painful; 
the rest of the mouth may be involved and the process extend to the pharynx 
and even to the stomach; the breath has an unpleasant odor. Treatment: The 
teeth should receive the careful attention of a dentist. A good remedy is pre- 
cipitated chalk pressed between the teeth at bedtime. During the day milk of 
magnesia may be used repeatedly as a mouth- wash. 

2. Dental Caries. — The rapid decay of the teeth seen in many women during 
pregnancy is not due to the deficiency of lime salts in the blood, as it has never 
been shown that there is such a deficiency ; but it is undoubtedly caused by the 
acid eructations, vomiting, and secretions, the result of acid dyspepsia of the 
early months of gestation. I have frequently noted in my private practice that 
the number of teeth attacked and the rapidity of dental caries were directly pro- 
portionate to the frequency, intensity, and persistency of acid dyspepsia with 
eructations and vomiting. Biro * has shown that mere pregnancy, aside from 
causing acid dyspepsia, has no effect on the teeth. One of the first duties of 
the obstetrician toward his patient in pregnancy is to inquire into the condition 
of the teeth and mouth, and, if necessary, to send the patient to her dentist. 
Dental caries lapping over into or originating during pregnancy should receive 
immediate attention. The carious substance should be partly or completely re- 
moved, the cavity touched with pure carbolic acid (an alkali), and a temporary 
gutta-percha filling put in. Severe and painful dental procedures, however, with- 
out the use of cocain or nitrous oxide, should be avoided, since they may lead 
to abortion. For prevention we have nothing so efficacious as the free use locally 
of alkalies, such as milk of magnesia, lime-water, or bicarbonate of soda, my 
preference being for the first. This should be used as a mouth-wash after each 
meal and at bedtime, care being taken to draw the fluid between the teeth. 
It may be used oftener when the vomiting of pregnancy is persistent. Small 
doses of milk of magnesia taken internally will often correct acidity, relieve vom- 
iting, and thus prevent dental caries. If this affection occurs late in gesta- 
tion, no treatment should be applied for fear of miscarriage unless the pain 
should become so severe as to demand attention. If, however, it develops in 
the early months, a dentist should be at once consulted. The caries may 
be attended by severe pain, or it may progress without causing any discomfort. 
Toothache, attended by no apparent pathological changes in the mouth, may 
occur and' be very persistent; it is, however, apt to disappear after the first 
half of pregnancy. In all cases attention must be given to the dyspepsia 
present. 

* " Wien. med. Blatter," 1898. 



DISEASES OF THE ALIMENTARY TRACT. 365 

3. Oral Sepsis. — The mouth should be examined in all cases Of fever or 
septic symptoms occurring during pregnancy or the puerperium, and particu- 
larly in instances of persistent nausea and vomiting of pregnancy. Many 
pregnant women, consciously or unconsciously, hai~e ulceration from caries 
going on at the root of an old molar, which intermittently discharges a foul pus 
at the edge of the gums (pyorrhoea alveolaris). Again, the rapid increase in the 
use of bridges and gold caps over old broken-down fangs is, I am sure, an 
important factor in oral sepsis. Often we find bone necroses under these caps 
and bridges, and pus organisms from this source are most virulent. Not only is 
this local septic condition a cause of stomatitis, but it is, the author feels sure, an 
important and prevalent cause of gastric disturbances and systemic infection. 
In one of my cases a second molar, decaying and ulcerating at the roots, was 
removed under nitrous oxide by Dr. Hasbrouck, of Xew York, in the middle of 
gestation; this was followed by a distinct improvement in pronounced gastric 
disturbances present, and a cessation of symptoms which resembled an atypical 
form of malarial infection, and which were attributed at the time to imperfect 
plumbing. In my belief these general phenomena were septic in character. 
Treatment: The source of the pus should be removed, with the use of nitrous 
oxide if necessary; especially should necrosed and useless fangs be extracted, and 
proper drainage effected. More attention should be given to oral antisepsis 
than has hitherto been the custom; caps and bridges should be avoided; all 
removable mouth plates should be sterilized daily; in cases in which, for any 
reason, removal of necrosed teeth is not advisable, or the patient refuses 
to have it done, the stump should be thoroughly touched daily with carbolic 
acid (1 : 20), and several times a day an antiseptic mouth-wash, such as per- 
oxide of hydrogen (1 : 4), should be used. 

4. Salivation or Ptyalism. — This occurs most commonly in the early months 
of pregnancy, and consists- in a profuse secretion of saliva; the patient suffers 
from a continual dribbling which is very annoying; the condition is supposed to 
be due to a neurosis or toxemia. Sometimes the amount of saliva expectorated 
in twenty-four hours will reach two or more quarts. The general health 
may even be impaired by this trouble; and in certain instances the affection 
continues to term, and, very exceptionally, for some months after labor. The 
danger to the patient lies in the inanition which results from this drain on the 
system. Interesting examinations of the constituents of this saliva have shown 
several changes from the normal: the organic and inorganic substances are 
diminished, while the water is much increased; in Schramm's case the ptyalin 
was absent, so that the saliva had no digestive properties left. The mucous 
membrane of the mouth becomes red and swollen; there is no fetor, and this 
distinguishes the affection from mercurial ptyalism. Treatment: Astringent 
tablets, such as troches of tannic acid, and count erirritation over the parotids are 
useful; the bromides are most often of service; atropin or belladonna may be 
tried; careful attention to the general health is necessary. 

5. Anorexia. — Complete anorexia sometimes occurs; more commonly there 
is a disgust for particular kinds of food, rather than absolute anorexia. This 
condition is apt to manifest itself at either extreme of pregnancy, when the 
neurotic features are most predominant. Sometimes the patient will not be able 
to bear the thought of meat of any kind; again, she can take nothing else but 
meat. Treatment: Tonics and vegetable bitters are useful; the liver and 
bowels should be carefully regulated, and the patient should be humored as 
much as possible in the choice of food. 

6. Nausea and Vomiting. — (See Toxemia of Pregnancy, page 324.) 



366 PATHOLOGICAL PREGNANCY, 

7. Pernicious Vomiting ; Hyperemesis Gravidarum. — (See Toxemia of Preg- 
nancy, page 324.) 

8. Malacia ; Longings. — Patients will occasionally show a perverted appetite 
for unnatural and unheard-of articles of diet. This affection is also designated 
as pica, or more popularly as pining. In very rare cases it may be exaggerated 
to true insanity. Gentle treatment may have some effect ; the mind should be 
diverted; hygiene, particularly of the alimentary tract, should be carefully 
looked after, and, if necessary, moral suasion should be tried. Labor terminates 
these symptoms. 

9. Gastric and Intestinal Indigestion. — These affections often occur in preg- 
nancy, especially in primigravidse. Pyrosis or heartburn is particularly trouble- 
some in the gastric form, enteralgia being most striking in the intestinal dis- 
turbance. These discomforts are manifest most often in late pregnancy. 
Treatment: Attention to diet and the relief of constipation may be all that will 
be necessary. Alkalies are frequently useful in pyrosis. Pepsin, pancreatin, 
diastase, powdered calumba, the alkaline mineral waters, and an occasional 
dose of calomel may be symptomatically indicated. In the intestinal 
indigestion of pregnancy I have obtained good results from a mixture 
of hydrastis, bicarbonate of potassium, and pancreatin or essence of pepsin 
(Fairchild). 

10. Constipation. — This is a common accompaniment of pregnancy, and is 
due partly to pressure, but mostly to deficient innervation of the muscular 
coat of the bowel, causing an exaggeration of the normal intestinal torpidity of 
women. Women sometimes pass a week or more without defecation, and 
then copraemic symptoms, such as mental dulness, dizziness, distended veins, and 
headache, are apt to supervene. The direct mechanical pressure of the enlarging 
uterus on the intestines has been shown by frozen sections to be almost insignifi- 
cant. However, the distended anterior abdominal wall is deprived of much of 
its power as a factor in defecation. Constipation has a tendency to cause 
hemorrhoids, and may even, by accumulations in the colon, predispose to 
abortion. 

Treatment should be prophylactic, as far as possible; the trouble should be 
anticipated early in pregnancy by a laxative diet, including fruits, and an 
abundant quantity of plain water, drunk at bedtime and on rising in the morning. 
In the curative treatment violent cathartics must be avoided, as they usually 
exaggerate the condition subsequently, and have been known to interrupt 
pregnancy. In neglected cases of several days' standing repeated enemata of 
sweet oil and ox-gall may be necessary to unload the impacted rectum, or even 
the mechanical use of the spoon, followed by enemata. Ordinarily the best 
results will be obtained by the use at bedtime of pills containing varying quanti- 
ties of aloin, cascarin or extract of cascara, extract of belladonna, strychnin, 
podophyllin, and capsicum. These pills or tablets may be obtained the world 
over. Experience has taught me that one formula will not be suitable 
for all; he is, therefore, accustomed to use as many as six different combinations, 
according to the nature of the case. It will sometimes be necessary to try three 
or four different formulae, until a suitable one is found. Extract of cascara sagrada , 
I gr. (0.03); cascara sagrada cordial, one or more teaspoonfuls (4 to 8); fluid 
extract of cascara, in increasing doses, after meals or at bedtime; compound 
licorice powder, capsules, tablets, or pills of inspissated ox-gall, 2 grains (0.12); 
extractum pancreatis, 2 grains (0.12); and extract nux vomica, J grain (0.015); 
after meals and at bedtime; small doses of Apenta, Birmenstarff, Marien- 
bad, Hunyadi, Friedrichshalle, Villacabras, or Rubinat-Condal waters, an hour 



DISEASES OF THE ALIMENTARY TRACT. 367 

before breakfast, are all reliable remedies; but a suitable one for each individual 
case must be chosen. For years I have been in the habit of using combinations 
of these waters, as Marienbad and Birmenstarff, equal parts; Birmenstarfl half a 
tumblerful and Villacabras one or two tablespoonfuls ; Friedrichshalle half a glass, 
and one or two tablespoonfuls of Villacabras, or four tablespoonfuls of Rubinat 
water. Combinations of Apenta and the stronger purgative waters can be made 
in the same way. I have found Friedrichshalle water, one-third of a tumblerful, 
and Saratoga Hawthorne water two-thirds, a pleasant and valuable laxative 
and a marked diuretic. 

•• Enemata of plain soapsuds, and of oil, glycerin, and ox-gall, as well as laxa- 
tive suppositories of glycerin and gluten, are occasionally useful, but should 
not be used continuously for fear of irritating the rectum. Various pastes con- 
taining figs are often useful. A good laxative fig paste is made from one pound 
of figs, two ounces of senna, one ounce of coriander seed, and sugar enough to 
make a paste. Small quantities of this paste may be taken at bedtime, or even 
after meals. 

ii. Diarrhea. — This is not common, but occasionally 'occurs as the result of 
irritation from pressure, and from errors in diet. If severe, it may cause an 
interruption of pregnancy, hence it is more serious than constipation, and when 
it amounts to dysentery it is most unfavorable . The treatment consists in the 
use^of astringents, such as tannin or aromatic sulphuric acid, combinations of 
opium, bismuth, chalk, and zinc, and, in neurotic subjects, the administration 
of nerve sedatives and bromides. 

12. Hemorrhoids are common, on account of the general pelvic congestion 
incident to pregnancy, and the direct effect upon the circulation of the uterine 
pressure. They are often due to constipation and straining. Very rarely are 
the hemorrhoids of pregnancy the cause of severe hemorrhage, anal fissures, 
and fistulae; nevertheless they cause intense discomfort and even suffering. 
Treatment: Operations are to be avoided, as likely to induce premature labor. 
The recumbent position, and the frequent assumption of the knee-chest position, 
will be useful; constipation should be avoided; benefit may be derived from the 
use of astringent and anodyne ointments and suppositories; e. g., unguentum 
gallas, unguentum stramonii, equal parts; opium suppositories; compound oint- 
ment of galls. The application of fluid extract of witch-hazel upon a compress, 
and this in turn covered with an ice-bladder, will often afford relief. For the 
constipation, sulphur, alone or in combination with aloin and extract of bella- 
donna, is valuable. 

13. Jaundice ; Icterus Gravidarum. — (See Toxemia of Pregnancy, page 
3 2 4.) 



368 PATHOLOGICAL PREGNANCY. 



XIII. DISEASES OF THE CIRCULATORY SYSTEM. 

I. Acute Endocarditis. 2. Chronic Endocarditis. J. Affections of the Heart Mttscle. 4. 
Varicosities, 5. Aneurism. 6. Palpitation. 7. Syncope. 8. Hydremia. g. Perni- 
cious Anemia. 10. Exophthalmic Goiter. 

i. Acute Endocarditis. — This affection not only has an injurious influence upon 

pregnancy, but it is also apt itself to become extremely grave. Pulmonary 
congestion is sure to exist from the impeded action of the heart. (Edema of the 
lungs causes the blood to be dammed back on the heart, and there result cardiac 
failure and fatal syncope. The most usual time for the occurrence of this acci- 
dent is during or just after the birth of the child, and it is caused by the extra 
strain on the heart, coincident with the circulatory changes due to the lessened 
intra-abdominal pressure. Regarding treatment, induced labor will be demanded 
with the rapid emptying of the uterus after dilatation, nitrous oxide or ether 
being used if compensation is absent. Digitalis is often useful in the first stage 
of labor, and forceps always in the second. Moderate hemorrhage in the third 
stage, or just after it, relieves the symptoms of cardiac embarrassment. Nitrite 
of amyl has proved useful after labor. 

2. Chronic Endocarditis. — This is often followed by a fatal termination, due 
to the fact that the hypertrophy which already exists, and has been sufficient to 
make up for the strain of pre-existing valvular lesions, is no longer able to meet 
the extra demands of pregnancy. The heart may be already weakened by 
disease, and then be attacked by a fresh inflammatory trouble, as is usually the 
fact in more recent cases. One great danger in all cardiac cases, especially 
those with acute symptoms, is embolism. Pulmonary troubles are also apt to 
supervene in the last half of pregnancy, from exposure to cold or exertion. 
Pulmonary congestion and oedema may occur with fatal result. Valvular 
disease may prove a very unfavorable complication, and this is largely due to 
the same reasons which render the prognosis so unfavorable in pneumonia, and 
also to increased pressure in the blood-vessels, which is incident to pregnancy and 
labor. Death is often the result in severe mitral disease, the heart showing its 
weakness especially after expulsion of the child or placenta. The prognosis is 
unfavorable for both mother and child, although with proper care many cases 
will terminate favorably; placental apoplexy and abortion are common. Mitral 
lesions, especially mitral stenosis, are particularly to be dreaded. 

The treatment is symptomatic as regards the cardiac affection. The avoid- 
ance of overexertion and excitement is of the highest importance, and the 
hygiene and nutrition of the patient should be carefully guarded. The induction 
of labor must be considered if the symptoms become very grave. Inhalations 
of nitrite of amyl may be of service in cases of dyspnea and extreme high ten- 
sion; stimulants are to be given only if indicated. In cases of great embarrass- 
ment of the right heart, allowing the uterus to relax and bleed during the third 
stage will be beneficial. Anesthetics should be used with caution, ether being 
preferred. For obvious reasons the use of ergot is not advisable in cases with a 
tendency to contraction of the arterioles. Syncope should be guarded against 
by the application of the abdominal binder before delivery, which is gradually 
tightened during the emptying of the uterus. I have found careful atten- 
tion to nutrition and the secretions, enforced rest with massage, and the 
prolonged and free use of strychnin of great help in bringing a case of chronic 
valvular disease to the period of viability, or even to full term. During labor he 
uses ether, and hastens the dilatation as much as possible by bimanual stretch- 



DISEASES OF THE CIRCULATORY SYSTEM. 



369 



ing, giving digitalis if indicated, strychnin always, and he always shortens the 
second stage with forceps. Venesection would often be useful, were it not for 
the unfavorable moral effect. 

3. Affections of the Heart Muscle. — There can be no doubt that in cases of 
valvular lesions the hypertrophy, which before pregnancy was sufficient for 
compensation, may become insufficient in view of the increased demand, and 
thus may lead to serious symptoms. Fatty degeneration may occur as the 
result of the toxemia of renal disease, or of septic infection; brown atrophy has 
been observed in a few instances. The existence of myocarditis should cause 
grave apprehensions, because the heart is hindered from adequately developing 
to meet the demands made on it by the valvular lesions added to pregnancy. 

4. Varicosities. — Varicose veins, especially of the thighs and lower gluteal 
region, are very common (Fig. 482). 

Those of the vulva, vagina, and rectum 
have already been noted (Fig. 477). 
Varicosities also occur within the pelvis, 
especially in the broad ligaments, and by 
their rupture may cause pelvic hemato- 
cele; the occurrence of hematuria from 
the rupture of varicosities of the bladder 
has been noted. The chief cause is the 
obstruction to the return circulation, by 
the pressure of the gravid uterus. Predis- 
posing causes are the increased amount of 
blood in the circulation, and changes in 
the walls of the vessels, such changes being 
favored by renal disease and hydraemia. 
Multigravidae are more often subject to 
this trouble than are primigravidse. The 
saphenous vein is always the first vessel 
affected. Pain, especially upon standing 
or walking, and with an itching sensation 
over the dilated vein, are common symp- 
toms ; sensations of intrapelvic weight and 
pressure may occur. The prognosis is good 
with proper treatment, but the possible 
occurrence of rupture should not be forgot- 
ten; such an accident may be followed by 
most alarming hemorrhage. Thrombosis 
and phlebitis are possible complications. 

Treatment. — The patient and friends should be warned of the possibility of 
rupture, and should be furnished with a compress and bandage, instructed in their 
use, and how, in case of hemorrhage, the limb should be elevated. Constipation 
should be avoided, and the patient should spend a good deal of the time in the 
recumbent position, with hips and legs elevated. Varicosities of the lower 
extremities should be treated by the use of properly fitting elastic stockings, or 
carefully applied bandages. Varicosities of the vulva should be supported by 
a pad and a T-bandage. In all cases, too much standing or walking should be 
avoided, and there should be no constriction about the waist. An abdominal 
supporter may help to prevent excessive uterine pressure (Fig. 233). 

5. Aneurism. — This is not common during pregnancy, but "is of clinical 
importance, because of the danger of rupture from the straining efforts of the 

24 




Fig. 4S2. — Varicose Enlargement 
of the Left Saphenous Vein in a 
Pregnant Woman. 



370 PATHOLOGICAL PREGNANCY. 

second stage. The careful administration of an anesthetic, and the termination 
of labor as soon as is consistent with due regard to the interest of the mother, are 
advisable. 

6. Palpitation. — This is a frequent occurrence. It may be of neurotic origin 
or reflex, from upward pressure of the uterus on the diaphragm; in many cases, 
no doubt, both elements contribute to the causation; in the absence of organic 
disease it is not usually of great importance. Treatment: Nerve sedatives may 
at times be indicated, but as a rule it is better to attend to the general hygiene of 
the patient and the removal of reflex causes — e. g. , constipation. Moderate exercise 
in the open air is beneficial ; causes of excitement and worry should be removed 
if possible. Should the condition of high arterial tension exist, profuse watery 
stools produced by the use of calomel and salines may be required, and rest with 
careful diet insisted upon. If the trouble is the result of mechanical difficulties 
in the last part of pregnancy, hygienic measures, together with antispasmodics, 
may give some relief, but only when the uterus begins to sink will permanent 
relief occur. 

7. Syncope. — A special syncope of pregnancy is mentioned by some writers 
as a manifestation of hysteria. Its consideration belongs under the latter head. 

8. Hydrsemia ; Serous Cachexia ; Serous Plethora. — An increased fluidity of the 
blood was formerly supposed to exist during the whole of pregnancy. Recent inves- 
tigations have tended to show that in the latter months the proportion of hemo- 
globin and the number of red corpuscles are increased. There is no doubt, how- 
ever, that hydrsemia does exist in a large proportion of cases, especially in 
ill-nourished subjects, in consequence of the increased demands upon the 
maternal circulation. Not uncommonly in hydrsemia there is swelling of the 
lower extremities extending upward even to the lower segment of the uterus. 
If there are no kidney complications, danger need not be anticipated, but the 
discomfort caused is excessive. Nervous manifestations are common ; there is a 
sense of fulness in the vessels, with disagreeable pulsation of the arteries; flashes 
of heat, imperfect vision, and dyspnea are present; dull aching in the sacral 
region, and a diminution of the fetal movements, and even toxic symptoms may 
occur. The diagnosis is clear from the history of the case and from the blood- 
examination. The latter reveals an abnormal amount of serum, a decreased 
number of red blood-cells, less albumin and iron, and increased fibrin. The blood, 
after being taken from the vessels, forms a clot with abundant serum floating 
about it, closely resembling that of chlorosis. The whole amount of fluid is often 
much more than normal. The prognosis is generally good. The symptoms quickly 
subside after the child is born, and prematurely induced labor is necessary 
occasionally only. The treatment consists in careful attention to the secretions ; 
the persistent administration of some readily assimilated preparation of iron, 
as the peptomanganate or albuminate of iron, with cod-liver oil; careful attention 
to the diet; forced feeding if necessary; massage, with a change of air and 
environment. 

9. Pernicious Anemia. — This condition is also known as progressive anemia; 
it is of rare occurrence, and its etiology is obscure. It may be due to a previous 
anemia or chlorosis, from whatever cause; and when once established, there is a 
continuous progression till death either threatens or occurs; no serous plethora, 
as in hydrsemia, takes place, and there is only a slight oedema. Examination of the 
blood shows slight hydrsemia, and a diminution of albumin and of the number of 
red blood-corpuscles. There are progressive pallor and emaciation, with exhaus- 
tion ; the syrhptoms resembling those of a severe attack of chlorosis. Loss of 
appetite, hemorrhages from mucous surfaces, and attacks of vertigo and faint- 



DISEASES OF THE RESPIRATORY SYSTEM. 371 

ness are common. The nervous system is not well balanced; profound inanition 
may ensue, and the patient may die comatose. The ovum may or may not 
be prematurely expelled. The diagnosis is simple and the prognosis bad. 
Everything possible should be done to improve nutrition; tonics, especially iron, 
should be used, a reliable preparation of the peptonate or albuminate being 
usually preferable; arsenic is usually valuable; change of air and scene may be 
of great service; the inhalation of oxygen is highly recommended; correction of 
the gastro-intestinal catarrh which frequently coexists is most important; the 
induction of abortion may become necessary. 

10. Exophthalmic Goitre. — In 1895 Theilhaber* collected the reported 
material on the relationship of Basedow's disease and pregnancy, and the con- 
nection between the same affection and the puerperium and lactation. In 
pregnancy a minority of cases of coincidence of the two conditions shows that the 
disease was cured or improved by gestation, while in an excessive majority the 
disease was made worse. Theilhaber sees in the relationship between Basedow's 
disease and pregnancy a parallel to the frequent occurrence of neuroses during 
the same condition (neuralgia, epilepsy, chorea, etc.). The relation between 
Basedow's disease and the puerperium is as inconstant as the above. It has 
frequently been observed that the disease developed during the puerperium and 
then subsided, to reappear at a subsequent puerperium; and something of the 
same nature has been observed in connection with lactation. Kleinwachter 
claimed that the atrophy of the uterus often associated with Basedow's disease 
was of a nature to exclude the possibility of gestation; but in a patient of Theil- 
haber the woman conceived after years of uterine atrophy and amenorrhea. It 
is best to dissuade girls with Basedow's disease from marriage. Those already 
married should be forbidden to conceive, for the good reason that both gravidity 
and the puerperium frequently aggravate the disease greatly, and that the off- 
spring of such women are often highly neuropathic. On the other hand, if 
pregnancy is already established, the prognosis is not sufficiently grave to indicate 
its interruption unless the cardiac musculature is seriously compromised. In 
cases of child-birth in these goitre subjects prolonged lactation is contraindicated. 



XIV. DISEASES OF THE RESPIRATORY SYSTEM. 

I. Hyperosmia. 2. Bronchitis. 3. Pneumonia. 4. Emphysema. 5. Pleurisy. 6. 
Hemoptysis. J. Pulmonary Tuberculosis. 8. Acute Miliary Tuberculosis, p. Dyspnea 
of Pregnancy. 10. Nervous and Spasmodic Cough, n. Asthma. 

i. Hyperosmia. — Pregnant women of nervous temperament are sometimes 
annoyed by an abnormal development of the sense of smell. Unpleasant odors 
should be avoided as far as possible, and pleasing ones substituted, as the condi- 
tion may predispose to nausea and vomiting, and even be an important factor in 
the production of the pernicious vomiting of pregnancy. 

2. Bronchitis. — During pregnancy this is of no special significance, except 
that violent coughing may induce abortion. In all respiratory diseases, however, 
it should be remembered that the hydremia of pregnancy predisposes to pul- 
monary oedema. 

3. Pneumonia. — (See Infectious Diseases.) 

4. Emphysema. — This frequently occurs in an aggravated form, and may 
cause abortion, from the retention of carbonic acid gas in the blood; the influ- 

*"Arch. f. Gynakol.," 1895. 



372 PATHOLOGICAL PREGNANCY. 

ence of this gas in causing uterine contractions is noted in connection with the 
etiology of abortion. Symptomatic treatment, with counterirritation of the 
chest, is indicated. It is possible that the inhalation of oxygen, from the relief 
it affords, may tend to prevent abortion. Careful watch must be kept for 
symptoms of weakening heart, and should they ensue artificial labor may be 
demanded. 

5. Pleurisy with effusion, owing to the diminished breathing space, and the 
additional work thrown upon the heart, is a dangerous complication of pregnancy. 
If the effusion becomes purulent (empyema), the danger is manifestly increased. 
If the condition can be relieved by the evacuation of fluid, by aspiration or other- 
wise, the procedure is imperatively indicated; otherwise the treatment is symp- 
tomatic. 

6. Hemoptysis may occur, in connection with overaction of the heart, 
during the last few months of pregnancy, without organic pulmonary disease, 
and is most common in women of highly nervous temperament. The treatment 
should include absolute rest and quiet, and the use of sedatives, particularly the 
bromides. 

7. Tuberculosis and Pregnancy. — The subject of the relationship between 
tuberculosis and pregnancy has recently attained an increased degree of impor- 
tance, through the agitation in f avor of the justification of abortion in the tubercu- 
lous pregnant woman. A sort of traditional view still exists in the minds of 
some medical men and laymen, that pregnancy may sometimes arrest the devel- 
opment of consumption. 

Pregnancy a Predisposing Cause of Tuberculosis. — Statistics appear to 
show, according to Lancereaux, that a considerable number of cases of tubercu- 
losis develop solely as a result of pregnancy. The morbific action of the bacillus 
is not discredited by this statement, which simply means that the woman who 
became tuberculous , had no family history of the disease, was not of the scrofulous 
or tuberculous habit, had never been exposed to the hazard of contagion, and 
was living at the time of the infection in a good sanitary environment. Assum- 
ing, as Lancereaux does, that the bacillus is omnipresent, we must conclude that 
pregnancy by itself can render a healthy individual " tuberculizable." If preg- 
nancy can thus affect the healthy, how much more likely would it be for the 
disease to assert itself in a woman who is a fit subject for it, or in one who is 
actually consumptive? In the former class are so-called " candidates for tuber- 
culosis," who have a family history of the disease, of much significance under 
these circumstances ; one should strongly dissuade girls with tuberculous history 
and antecedents from early marriage, fearing that rapid child-bearing will infalli- 
bly light up the dreaded malady. What has been said of the " candidates for 
tuberculosis " applies with the same or greater force in the case of so-called latent 
tuberculosis, and of apparent recovery from the disease. It must not be under- 
stood that exceptions may not occur, and that tuberculous suspects necessarily 
become phthisical after pregnancy. The influence of pregnancy, whether single 
or repeated, upon such women represents a tendency rather than a law, but the 
physician's responsibility is not lessened by this fact, and he must necessarily be 
something of an alarmist, in order to advise his patients upon the safe side. The 
circumstances and environment of the woman, and the general prognosis of preg- 
nancy, aside from the question of tuberculosis, should have great significance in 
the matter of forbidding or interrupting a pregnancy. In a case of uncontrollable 
vomiting, for example, the fact that the woman is a tuberculous suspect would 
have much weight in influencing the physician to interrupt the pregnancy. 
Future generations must decide as to whether pregnancy in the tuberculous 



DISEASES OF THE RESPIRATORY SYSTEM. 373 

woman should be interrupted as a routine procedure. Present sentiment is be- 
ginning to dissuade such women from marriage, not less for their own benefit 
than for the sake of posterity, and all organized movements which are seeking to 
eradicate tuberculosis from the world lay much stress on discouraging marriage 
in tuberculous suspects. As long as this view prevails, there will necessarily be 
some justification for interrupting pregnancy already under way. 

On the other hand, it is claimed that incipient phthisis is no longer a fatal 
affection, and that two-thirds or more of such cases may be cured, or at least 
brought to a standstill. If this view be accepted, we have no statistical evidence 
to show that consumption which develops during pregnancy may be cured or 
arrested. If the disease develops early in pregnancy, the woman must go on for 
a number of months before she can become a fit subject for treatment, and this 
delay would of course militate greatly against her chances of recovery. Sana- 
toria for consumptives do not care to admit pregnant women, and this prohibi- 
tion is equivalent to ranking them as incurable. It cannot be denied that such a 
custom as the induction of abortion, in mere tuberculous suspects, might readily 
become a source of abuse, by furnishing a pretext for malpractice; but, at the 
same time, the fact that a candidate for tuberculosis runs a very great risk of 
becoming a consumptive through child-birth is a most stubborn one, and when, 
in addition to becoming a consumptive herself, she also brings into the world an 
individual who is likely to become tuberculous, it readily becomes apparent that 
the question of the propriety of therapeutic abortion is bound to become an issue 
in the future, in the practice of obstetrics. 

Pregnancy and Actual Tuberculosis. — Asa general rule, gestation exerts 
a distinctly unfavorable influence upon the disease. The presence of the gravid 
uterus interferes with respiration and the aeration of the blood, while the nausea 
and vomiting of pregnancy tend to interfere with assimilation ; but the real expla- 
nation of the fatality through which pregnancy leads to phthisis is as yet undemon- 
strated. Despite the fact that a pregnancy is often sufficient to bring about 
tuberculosis, it cannot be said that an incipient case of the latter is much acceler- 
ated by one parturition. As a general rule, it may be stated that the more 
advanced the pulmonary mischief, the greater the untoward effects of child- 
birth. Generally speaking, the ill effects of pregnancy are not apparent during 
the very first months, and some observers regard the fifth month as the period at 
which the course of the disease is seen to be modified by the woman's condition. 
However, the danger to the woman is present not alone through the course of 
the pregnancy, but in the puerperium as well. A tuberculous woman may go 
through gestation with no undue acceleration of her malady, only to succumb, 
after delivery, to acute general tuberculosis or acute tuberculous pneumonia. 

Some forms of pulmonary tuberculosis are much less influenced by pregnancy 
than others, and it is generally held that the so-called fibroid phthisis is hardly 
modified at all, either during gestation or after delivery. This important fact 
should be borne in mind in practice, because a woman with fibroid phthisis is 
probably capable of child-bearing. In sharply localized tuberculosis the effect of 
pregnancy by itself does not appear to be unfavorable, and it is even claimed that 
the woman with such a lesion is better during gestation. The efforts of the lungs, 
cramped as they are by the gravid uterus, to obtain oxygen constitute a species of 
pulmonary gymnastics, and, as a result, the tuberculous focus does not increase 
in size. But the situation may change immediately after delivery. The great 
strain of labor appears to mobilize the bacillus. The loss of blood, and the 
shock and fatigue, lower the resistance. The stimulus to forced inspiration is 
no longer present. Under all these circumstances the local process may suddenly 






374 PATHOLOGICAL PREGNANCY. 

increase, and an acute infection of the lung tissue, or generalization of the tuber- 
culous disease, may occur. The claims made by Pinard and other observers, 
that phthisis may undergo spontaneous resolution during pregnancy, may pos- 
sibly rest upon an erroneous interpretation of facts, and in any case such a 
sequence must be very rare. If spontaneous recovery does occur, it is prob- 
ably in cases of single and sharply circumscribed foci of disease. 

Obstetric treatment has now come to be regarded as the proper course, theo- 
retically at least, but meets with considerable opposition and even condemnation 
from conservative sources. Bossi, who has practised this form of intervention for 
ten years, has had only about twenty cases to his credit ; whence it is to be inferred 
that the necessity for intervention does not arise so often as one would naturally 
suppose. Results appear to show that when done under favorable circumstances 
— general condition fairly good, pregnancy not very far advanced — intervention 
holds the disease in check to a decided extent. A word as to the child of the 
tuberculous mother. While these women often bear healthy and well-nourished 
children, a comparison of the issue of phthisical individuals with those of healthy 
stock will show, on the part of the former, an inferiority in size and weight, and 
a greater vulnerability and mortality early in life ; and all this irrespective of 
the prospect of developing some tuberculous disease. Tuberculous pregnant 
women, also, show no little tendency to abort. 

8. Acute miliary tuberculosis occurring during pregnancy is a rapidly fatal 
disease and is frequently mistaken for septic infection. 

9. Dyspnea of Pregnancy. — This condition is marked by paroxysms resem- 
bling those of spasmodic asthma, and occurs most frequently in patients of ner- 
vous temperament. Dyspnea from purely mechanical causes, such as upward 
pressure upon the diaphragm, frequently occurs in the later months of pregnancy, 
and can best be relieved by loose clothing and the avoidance of constipation. It 
usually disappears spontaneously with the descent of the uterus, which takes 
place at the onset of the preparatory stage of labor about two weeks before term. 
Antispasmodics and nerve sedatives, and in severe cases the inhalation of 
oxygen, are useful. 

10. Nervous and Spasmodic Cough. — Coughing of reflex origin and without 
organic change in the respiratory tract sometimes occurs in pregnant women, 
especially those of nervous temperament. The paroxysms may be so severe as to 
induce abortion. It is best treated by nerve sedatives, such as the bromides, 
chloral, valerian, and asafetida, and by the removal of the reflex causes; i. e., 
constipation, granulations or erosions of the cervix. In a severe case which 
resisted all other treatment, I obtained a cure at the sixth month by curetting 
away granulations from the vaginal portion of the cervix and cervical canal, and 
touching all raw surfaces thus produced with pure carbolic acid. Pregnancy 
was not in any way interfered with. 

11. Asthma. — In asthmatic subjects the paroxysms are exceptionally severe 
during pregnancy, and demand the same treatment as in the non-pregnant state, 
oxygen being of great value. Certain women have asthma only in pregnancy, 
and the appearance of a paroxysm then becomes evidence of the patient's condi- 
tion. The general prognosis is somewhat unfavorable for mother and child. 
Fetal and maternal death have occurred as a direct result of asthma, and thera- 
peutic abortion is sometimes required.* 

* Audebert: Paris Internat. Congress, 1900. 



DISEASES OF THE NERVOUS SYSTEM. 375 



XV. DISEASES OF THE NERVOUS SYSTEM. 

I. Cerebral Disease. 2. Gestational Melancholia, Mania, and Dementia. 3. Vertigo and 
Syncope. 4. Insomnia. 5. Gestational Paralysis. 6. Gestational Neuralgias. 7. Neu- 
roses. 

i. Cerebral Disease. — Apoplexy has little influence upon the course of either 
gestation or labor. Inflammatory diseases are rare and accidental, and their 
influence upon the course of pregnancy is slight, except in the case of cerebro- 
spinal meningitis; since this latter is infectious, it has an effect upon pregnancy 
similar to other infectious fevers. 

2. Gestational Melancholia, Mania, and Dementia. — Insanity rarely has its 
origin during pregnancy, but may occur and present the types of mel- 
ancholia, mania, or dementia, the most common type being melancholia with 
a tendency to self-destruction. This rarely appears until the second third of 
gestation, and is most common in elderly primigravidas, especially the unmarried. 
The causes are pre-existence or predisposition, excessive fright, and prolonged 
anxiety. 

Maternity Insanity in General. — The term puerperal insanity has been gen erally used in 
such a sense as to comprise any psychical disturbances which antedate or follow the 
puerperium, within certain limits. This notion, according to the alienists, is loose and un- 
scientific. The term puerperal insanity should be restricted to manifestations which develop 
within from four to six weeks after labor, or, in other words, during the period of the lochial 
discharge. The complete relationship between child-bearing and insanity should be re- 
garded as follows: (1) Course of pregnancy, etc., in the known insane. (2) Insanity of 
pregnancy. (3) Insanity of the puerperium. (4) Insanity following the puerperium 
(lactation insanity). 5. To these might be added a fifth type occurring during the act of 
labor, from the high degree of suffering — insanity (delirium) during labor. In regard to the 
frequency of these types of insanity, it is claimed by alienists that some 10 per cent, or 15 per 
cent, of all the female insane who require asylum treatment derive their condition in some 
way from maternity. According to Abt, if 15 per cent, of insanity is due to maternity, the 
individual frequency would be as follows: insanity of pregnancy, 2 per cent.; insanity of 
puerperium, 9 per cent.; insanity of lactation, 4 per cent. These figures, however, have a 
limited value, for many cases of maternity insanity are so mild and transient that no incar- 
ceration is required. It appears safe to say that puerperal insanity, in the narrower sense, is 
the prevalent form, a fact not without significance in connection with the theory that there 
is some relationship between this type of psychosis and sepsis. 

General Etiology of Maternity Insanity. — Regarded independently of the particular phase 
of these psychoses, the chief etiological element is doubtless heredity; the proportion of such 
cases amounting to not less than one-half. In this connection, acquired insanity must also 
be mentioned as a factor. This condition may develop in those of sound heredity, as a result 
of acute infectious diseases, violent mental emotions, acute physical overstrain, etc. 

General Symptomatology. — This subject should likewise be considered without regard to 
any individual phase of maternity insanity. The symptoms are present in great variety, 
and all the familiar types of insanity are found within the domain of our present 
subject. Insanity of the depressive type, including melancholia, hypochondria, and 
imaginary fears, is sufficiently well represented. The melancholic type frequently 
exhibits a religious color, expressed by self-reproach, etc. The opposite type of mania 
is also common, with its exaltation, and increased bodily and mental activity. The 
expression of the latter may be harmless, consisting in mere pronounced eccentricity 
of various kinds; but it is also often violent so that restraint becomes necessary. 
Formerly comprised under mania, but now placed in a special category, is the hallucinatory 
type. Here there is neither exaltation nor depression, but the patient is simply deceived by 
her perceptive faculties. The state is therefore one of extreme confusion. Unrecognized or 
improperly treated, this type of insanity might become coequal in its results with mania. 
The impulses of the victim of maternity insanity to destroy herself, her children, or others, 
are now placed under the head of imperative conceptions, not necessarily connected or asso- 
ciated with any of the basic types of insanity. These phenomena are said to be noted par- 
ticularly when an inherited taint is present, and often they are the first expression of such 
inheritance. The further discussion of these insanities is continued under the special forms, 
and they are once more brought together under the head of treatment. 

Etiology. — Gestation may either awaken a hereditary taint of insanity, or the 
psychosis may develop de novo. In the latter case the resulting mental state may 



376 PATHOLOGICAL PREGNANCY. 

be regarded as an exaggeration of the disturbances of psychical equilibrium, 
so common in pregnancy, and in connection with menstruation, especially at the 
time of the establishment of that function. This type of pregnancy psychosis, 
then, is the least removed from the physiological status. The disturbed psychi- 
cal and nervous equilibrium so common in pregnancy would, in itself, occurring 
apart from that condition, constitute a mild type of psychopathy and neuropathy. 
We have only to call attention to the unnatural cravings, the blunting and per- 
version of taste and smell, the preternaturally acute sight and hearing, the re- 
markable changes in disposition, amounting almost to a reversal of temperament 
and transformation of character, etc. This type of insanity often appears to 
have a physical basis, and to stand in close relationship with anomalies of circu- 
lation, as shown by the very commonly encountered attacks of vertigo and 
fainting. Aside from the general causal factors already enumerated, a special 
factor is found, in the case of pregnancy insanity, in the shock and perturbation 
induced by the realization of the fa.ct that conception has occurred. This factor 
obtains chiefly in the unmarried, and in married women who, from any reason, 
can ill afford to submit to pregnancy. Death of a near relative during preg- 
nancy may have a similar effect. 

Symptoms. — Since the eccentricities of pregnant women are commonly 
understood, the borderland of insanity is frequently overlooked, and opportuni- 
ties for arresting the condition are consequently forfeited. An act of violence of 
some sort is the first intimation of the true state of the woman's mind. Many of 
the milder cases are so slight in degree, and of so short a duration, that they pass 
unrecognized, and thus help to invalidate the statistics of frequency and severity. 
As a rule, the character of the psychoses of the early months of pregnancy is of 
the depressive type; and, generally speaking, psychoses which supervene early 
in pregnancy tend to become worse with the aggravation of the physical condi- 
tions. Further, the numerous severe physical disturbances and diseases which 
may develop as pregnancy advances have a distinct tendency to aggravate the 
psychosis, causing it to pass into a more severe and pernicious type. Psychoses 
of pregnancy are prone to be continued after delivery ; a tendency which illustrates 
the futility of bringing on abortion under the circumstances. Imperative con- 
ceptions are prone to supervene during pregnancy, and they should be sharply 
watched for, in all pregnant women of psychopathic or degenerate stock. These 
conceptions, held under control by the will before pregnancy, begin at this 
period to be irresistible. Many of the morbid " phobias," so common in neuras- 
thenia, are also encountered under these circumstances for the first time. This 
sudden impairment of mental equilibrium appears to be due in many cases to the 
presence of vomiting, vertigo, and the like. The impulses to homicidal or 
suicidal violence, in the case of these women, often comes from the sight of a 
knife or other lethal weapon; or of an open window, etc. In some cases the 
women themselves confess to the presence of these impulses, while they are still 
able to master them. 

Treatment. — The keynote of successful treatment lies in early recognition of 
the psychosis. Prophylactic and general regimen comprises sufficient feeding, 
together with proper attention to all existing physical disorders. When the 
diagnosis is made, an alienist should be summoned in consultation. Hypnotics 
should be promptly administered, in the hope of procuring sleep and of control- 
ling the attack. When the general practitioner is obliged to depend upon him- 
self, no alienist or asylum being available, he can but carry out three general 
principles, without reference to the considerations which attend a nice diagno- 
sis. The patient must be (i) nourished, she must be made to (2) sleep, and 



DISEASES OF THE NERVOUS SYSTEM. 377 

finally she must be (3) prevented from inflicting injury upon herself, her child, 
or others. She should be kept upon the ground floor of the house, and all 
lethal weapons, drugs, chemicals, etc., kept out of reach. She should be kept 
in bed, and the bedding searched twice daily for secreted articles, which 
might be used with suicidal intent. The services of a good nurse are all- 
important. To restrain motor excitement, and thereby limit the danger of 
suicide, opiates are indicated, and in high degrees, morphin and hyoscin 
hypodermically. To secure sleep all external conditions must be made as 
favorable as possible, after which any good hypnotic, such as trional or chloral- 
amid, is indicated. If the patient will eat, she should be fed freely with simple, 
nutritious articles and weighed frequently. If food is refused, the stomach-tube 
must be employed. 

Various important questions arise in connection with the management of this 
affection. (1) Asylum treatment: While indicated in theory, this resource is 
directly contraindicated in practice, for the chances are that the patient will 
quickly recover and will never forgive her medical attendant for the stigma 
brought upon her (as she believes) by incarceration in an institution. The 
patient should instead have a trained attendant, and convalescence maybe has- 
tened by travel. (2) Interruption of pregnancy: This is never indicated, for 
the very good reason that it does not restore the patient's mind to the natural 
state. (3) Lactation: The patient should never nurse her child and the secretion 
of milk should be suppressed as soon as possible. (4) The element oj sepsis: The 
possibility that puerperal mania may have a septic element should be utilized in 
every possible way in the management of a case. The patient should have her 
parturient tract thoroughly examined. 

3. Vertigo. — We often observe a dizziness in highly nervous and hysterical 
women, independent of the toxemia of pregnancy. It must be remembered 
that an exaggeration of the usual hydraemia and anemia of gestation is often the 
real underlying cause, and can be relieved by attention to the blood conditions 
present. 

4. Insomnia. — Insomnia may occur with circulatory changes, or independent 
of them, due to the toxemia of pregnancy. When the former is the cause, the 
treatment consists in cathartics, diuretics, and diaphoretics. In other cases it is 
necessary carefully to regulate the diet, and to use nerve sedatives or anti- 
spasmodics, such as the bromides, sulphonal, camphor, valerian, and asafetida, 
care being taken to prevent a drug habit. 

5. Gestational Paralyses. — Paralyses in pregnancy are sometimes incorrectly 
termed puerperal paralyses. The nerves of special sense, or the facial nerves, 
may be affected, or hemiplegia or paraplegia may occur. Paralyses of the nerves 
of special sense may result in amaurosis or deafness, partial or complete. In the 
case of amaurosis, kidney insufficiency should always be suspected. Anemia of 
the retina may be the cause, and if injury to the latter has not occurred, the pre- 
mature interruption of pregnancy will result in a cure. Deafness is a rare and 
temporary condition, and may be either unilateral or bilateral; it may or may not 
be due to renal insufficiency. Facial paralysis is extremely rare, and is usually 
the result of profound anemia. Hemiplegia is not uncommon in pregnancy; it 
may be caused by cerebral hemorrhage or anemia, and does not necessarily inter- 
fere with pregnancy or parturition. Paraplegia may be the result of a spinal 
disease, or of pressure upon the pelvic nerves by the fetal head; the loss of volun- 
tary motion thus produced does not necessarily interfere with pregnancy or 
labor. Both these conditions may demand the premature interruption of preg- 
nancy, in addition to the use of strychnin, faradization of the affected limbs, 



378 PATHOLOGICAL PREGNANCY. 

and iron. Both hemiplegia and paraplegia are apt to disappear in the puer- 
perium. 

6. Gestational Neuralgias. — Neuralgic pains in various parts of the body, the 
uterus not excepted, are common. Toothache is often met with, and may be of 
functional or organic origin (see page 364). Neuralgias of the lumbar and recti 
muscles are also common, the latter being due to excessive stretching; sciatica 
often occurs in the latter part of gestation, as a result of pressure. Headache, 
when present, should always make us suspicious of renal insufficiency, as should 
localized neuralgic pains in the head, face, or breast, which are often symptoms 
of advanced renal disease in pregnancy. 

The treatment consists in careful attention to the excretions, especially 
those of the bowels and kidneys, and in the use of external and internal pallia- 
tive measures, such as sedative applications, nerve sedatives, and antispasmodics. 

7. Neuroses. — Hysteria is more or less common in all pregnant women. The 
existence of pregnancy renders the mental balance of the woman unstable, and 
an hysterical attack may be precipitated on the slightest occasion. True insanity 
has developed as a sequela. Syncopal attacks and hyperemesis are both regarded 
as of hysterical origin in many cases. The treatment is that of hysteria in 
general. Moral suasion is far more effective than are drugs. 

Epilepsy is a rare complication, because epileptics are usually sterile, and if 
gestation does occur, are often free from an attack during pregnancy, the disease 
returning in the lying-in state. It may be confounded with an eclamptic attack 
(see Eclampsia). Children born of epileptics usually die of congenital epilepsy 
when quite young. 

Chorea in its milder grades .is not uncommon; the causes being chlorosis, 
rheumatism, and heredity. Sixty per cent, of the cases occur in primigravidae. 
It usually appears in the first third of gestation, and shows a tendency to persist ; 
it is observed only during the waking hours, but if it is severe and persistent, inter- 
ruption of pregnane}' occurs. The maternal mortality is as high as 30 per cent. 
Gestational insanity is often a sequela. The causes of death are muscular exhaus- 
tion, heart failure, insanity, or the sequels of an interrupted pregnancy. The 
treatment in the milder cases consists of arsenic, given to the physiological point, 
iron, good hygiene, and carefully regulated diet. Severe cases, with tetany as a 
complication, may require anesthesia. The induction of premature labor 
usually results in a spontaneous cure. 



XVI. INFECTIOUS DISEASES. 

I. Variola. 2. Scarlatina. 3. Measles. 4. Typhoid. 5. Typhus. 6. Erysipelas. 
7. Malaria. 8. Pneumonia. g. Syphilis. 

These affections are also considered fully under the pathology of the fetus 
(page 285). In the present connection they are briefly treated from the maternal 
side. 

1. Variola. — This tends to run a severe course in the pregnant woman, cases 
of the confluent and hemorrhagic types being specially common. But mild 
cases, of course, occur in mild epidemics and in individuals protected in part by 
vaccination. Metrorrhagia occurs at times, and not necessarily in hemorrhagic 
cases. The frequency with which abortion occurs is directly proportional to the 
intensity of the disease. It is inevitable in the hemorrhagic type, almost inevit- 
able in the confluent type, but occurs only in a minority of cases when the 



INFECTIOUS DISEASES. 379 

disease is benign. Prophylaxis and treatment call for no special mention here. 
Pregnant women should invariably be vaccinated under the same conditions as 
other indviduals. 

2. Scarlatina. — This is considered elsewhere as a puerperal disease (Part VII). 
As a complication of pregnancy alone it is of rare occurrence, the gravid woman 
enjoying a relative immunity in comparison with the puerpera. Certain obstetri- 
cians hold that the disease may be latent during pregnancy, to assert itself after 
delivery. This is a mere opinion at present. Another view is that the exposed 
pregnant woman may transmit the disease to the fetus without herself becoming 
infected. Scarlatina which breaks out during pregnancy runs its course as in the 
non-pregnant. If the degree of infection is intense, abortion results. 

3. Measles. — This is rarely described as a complication of pregnancy. The 
gravid have no special immunity toward measles, but are chiefly protected by 
having had the disease in childhood. The course of the disease appears to be 
identical in the pregnant and the non-pregnant. Abortion is favored by the high 
temperature and cough paroxysms. The relative frequency of abortion is hard 
to ascertain, but in certain small series of cases it is high (3 out of 4 times, 5 out 
of 7, etc.). Complications of measles are rare, and there is on record but a 
single case of death from bronchopneumonia. It is claimed that the tendency 
to post-partum sepsis and hemorrhage is increased, so that unusual precautions 
should be taken to ward off these accidents. 

4. Typhoid Fever. — The severity of this affection in pregnancy is neither 
necessarily increased nor diminished. Statistics may give either a high or a very 
low mortality. The proportion of abortion and premature delivery is high, 
ranging, according to statistics, from 58 to 83 per cent. As a rule, all depends on 
the gravity of the case, although sometimes pregnancy will not be interrupted 
even in the most severe examples. Toxemia is doubtless the chief agent in 
bringing about abortion. Sepsis is said to be a common sequel of labor during 
typhoid fever, so that the patient becomes a victim of associate infection with 
two formidable maladies. 

5. Typhus. — The few data upon record do not admit of the drawing of 
any conclusions upon the course of the disease in pregnancy or the frequency with 
which abortion is produced. 

6. Erysipelas. — There is neither special disposition to nor immunity from this 
affection in pregnancy, nor is its course modified by the latter condition. Fatali- 
ties do not appear to have been recorded, and while abortion occurs with fre- 
quency, there are no statistics by which this may be determined. 

7. Malaria. — There is less than the normal susceptibility to malarial attacks. 
It is sometimes developed during the puerperium; it is, however, probable that 
many cases reported as malarial have been cases of unrecognized sepsis. When 
malarial fever occurs in pregnancy, it may pursue an atypical course; abortion 
seldom occurs. The fetus may suffer from this disease, being born with evidence 
of it; e. g., enlarged spleen. Quinin should be administered, as in the non- 
pregnant state. 

8. Pneumonia. — In this disease the prognosis is grave in late pregnancy, 
owing to the diminished breathing space, the hydrasmia, and the extra work 
which the heart has to perform. Interruption of pregnancy frequently occurs. 
The gravity of the disease and the tendency to miscarriage increase progres- 
sively during pregnancy, and are greatest in the later months. All the symp- 
toms are aggravated by labor, hence the induction of labor is not indicated. 
Premature labor or abortion should be prevented, if possible. However, if labor 
begins, it should be hastened within safe limits. The heart should be sustained, 






380 PATHOLOGICAL PREGNANCY. 

and the same general treatment be pursued as in the non-pregnant state; cupping 
and full doses of strychnin are of great service. 

9. Syphilis. — This is one of the most common causes of abortion (compare 
Placental Syphilis and Abortion). The virulence of the disease proper, however, 
does not seem to be increased, except that the initial lesion is apt to be very 
severe, owing, perhaps, to the genital hyperemia and the hypertrophy incident 
to pregnancy. 

The prognosis will depend, to a great degree, on the resistant power of the 
patient, as well as on the septic micro-organisms which are associated with the 
micro-organisms of syphilis. Fournier has said that " a syphilitic woman who 
becomes pregnant is more likely to abort than is a pregnant woman who 
becomes syphilitic." Treatment should begin as soon as the infection is dis- 
covered, and be pushed just short of salivation, being in general the same as 
that of the non-pregnant state. For the local lesions, antiseptic, sedative, 
and drying powders should be used. Besides medicinal measures, tonics and 
systemic nutritious feeding are demanded. 



XVII. SKIN DISEASES. 

I. Pruritus. 2. Pigmentation. 3. Herpes Gestationis. 4. Impetigo Herpetiformis. 5. Alopecia. 

Besides the ordinary affections of the skin, to which she is as liable as the non- 
pregnant, a pregnant woman may at times show eruptions which are intimately 
connected with her state. As a general rule, acne, psoriasis, and eczema are very 
much worse during the pregnant state. Not infrequently it happens that after 
its termination those of internal origin, eczema and psoriasis, disappear of them- 
selves. The exanthems of eruptive fevers are not modified by a pregnancy they 
complicate. 

1. Pruritus. — Itching is a symptom, not a disease. The term pruritus is 
limited in its use to conditions in which there are no evidences on the skin except 
those which result from scratching. 

When the diagnosis of pruritus is established, it remains to determine the 
causative factor. Parasites, pediculi, and the itch mite must first be excluded. 
Various excitants which are not necessarily connected with pregnancy, such as 
jaundice, intestinal intoxication, and nephritis, may operate in pregnant women. 
There may be localized pruritus of the genitals from diabetes or leucorrhea; 
of the anal region from rectal ulcers or hemorrhoids. In this climate there is a 
pruritus (pruritus hiemalis) which comes on at the approach of winter, affects 
chiefly the wrists and legs, and is probably due to feebleness of circulation. After 
these factors are excluded, there remains a pruritus of pregnancy. Its causation 
is doubtful, but it is probably due to irritation of the peripheral nerves by circu- 
lating toxins. There is no eruption when pruritus begins, but when the patient 
is seen, secondary ones due to scratching are present. They are blood-crusted 
excoriations, generally linear, which may show various infections. The char- 
acter of the latter are impetiginous or ecthymatous (see page 381). If the 
disease has lasted for any length of time, the skin is thickened, pigmented, 
and its lines are deepened. There is often an indolent enlargement of the 
lymph-nodes . 

Treatment. — When pruritus is local, the cause should be removed at once. 
In general itching, the eliminative functions of bowels, skin, and kidneys should 
be stimulated. Copious draughts of water are recommended as a routine 
measure. Internally, the opium derivatives are not to be thought of. The 



SKIN DISEASES. 381 

patient usually demands relief at once, so local measures are of first impor- 
tance. Practically all anti-parasitics are antipruritics — sulphur, naphthol, 
salol, menthol, thymol, camphor, and carbolic acid. They are used in lotion, 
alcoholic or watery, if the skin is not dry; if it is, ointments are preferable. 
It is better to use the latter in any case until pus infection disappears. In local 
pruritus, cleanliness is a necessity. Pledgets soaked in carbolic acid or Labar- 
raque's solution may be placed between the labia or in the anus. Silver nitrate 
(5 to 10 per cent, solution) painted over the parts is helpful. Antipruritics, 
as a rule, are best combined with diachylon ointment. 

2. Pigmentation. — Pigmentation in pregnancy, as in other states, may be 
primary or secondary to inflammatory disease, syphilis, zoster, lichen planus, 
dermatitis herpetiformis, or to pruritus. Pigmentation also appears in the 
course of cachexias, malaria, leukemia, tumors, and after the administration of 
arsenic. The specific pigmentation of pregnancy has sites of election — the face 
and chest, especially the breasts. Pigmentation of the areola and nipple can 
hardly be regarded as pathological. Clinically, the color varies from a golden 
yellow to a dark brown. The spots vary in size up to a universal involve- 
ment. They are formed by coalescence or peripheral extension. The borders are 
sharply defined and rounded. Involution begins, as a rule, in the oldest por- 
tions. There is no disease for which pigmentation may be mistaken except 
tinea versicolor. In the latter affection the scales may be readily scraped off, 
and always show threads and spores of its fungus. Metabolic pigmentation 
of any origin is pretty difficult to remove. That of pregnancy has more ten- 
dency to disappear spontaneously than is the case in other states, and when 
it occasions no distress to the patient's mind, it is quite as well to let it alone. 
If it is disfiguring, its involution can be hastened on unexposed parts by strong 
exfoliative applications, such as a 20 per cent, resorcin ointment or a 10 per 
cent, salicylic acid collodion or plaster. The inflammation set up has a distinct 
effect in promoting absorption. On the face, these things are likely to do 
more harm than good. Peroxide of hydrogen or pyrozone (the weaker solution) 
has sometimes a good effect. It must be applied five or six times a day. A 
favorite formula is bismuth suboxid, ammoniated mercury, aa 5j ', lanolin, §j. 
The application is to be stopped temporarily when scaling appears. 

3. Herpes Gestationis (Dermatitis Herpetiformis). — Its lesions are extremely 
varied; in fact, there is nothing distinctive about them. They consist of 
erythematous patches, not of great extent, sharply defined, without scales 
or infiltration; of papules which are tiny and pale, capped with blood crusts, 
like those of prurigo, or larger elements, red, pointed, and hard. On the patches 
of erythema or on the papules, vesicles may appear which can be found on 
parts not readily reached by the nails. Lastly, bullae may arise on a reddened 
base. The sites of predilection are the buttocks, backs of the thighs, flanks, 
and forearms, but in exceptional cases the eruption may spread over the whole 
surface. The mucous membranes are never attacked. The lesions all have 
a tendency to herpetiform grouping in clusters without coalescence, itch furi- 
ously, appear in successive crops, and leave deep pigmentation. The patient 
may get into a bad nervous condition with insomnia from the irritation. 

Etiology. — The disease is a pure neurosis. It follows shock and depressing 
conditions generally. There are no demonstrable lesions of the nervous system. 
It is a very rare complication of pregnancy. 

Diagnosis. — Diagnosis is founded on the multiformity of the lesions, their 
grouping, recurrence, the localization on buttocks, flanks, and extensor sur- 
faces, the intense pruritus and terminal pigmentation. In pregnant women 



382 PATHOLOGICAL PREGNANCY. 

there is often a history of recurrence in successive pregnancies in which the 
type of lesion may have changed but the other features have remained constant. 
Treatment. — Termination of pregnane}^ generally, but not always, brings 
an attack to a close. There are three things which are useful in the treatment 
of dermatitis herpetiformis. The first is rest, the second is arsenic, and the 
third is sulphur. The first is secured by a modified "cure," hydrotherapy 
(packs and Scotch douches), quiet, and forced feeding. Arsenic is given by 
the mouth or skin, to the point of toleration if any effect is desired. Sulphur 
is used externally in 10 per cent, ointment vigorously rubbed in after the bath. 
Prognosis is good as regards life, bad as to recurrence. 

4. Impetigo Herpetiformis. — It was formerly thought that this disease ap- 
peared only in pregnant women, but cases have occurred in the non-pregnant 
and in males. There appear about the ano-genital region, the umbilicus, 
axillae, and inside of the thighs, groups of pustules which spread peripherally 
until a large part of the surface is covered. The pustules become converted 
into thick crusts which on removal leave the surface reddened and tumid, 
the horny layer loosened and stripped away from the diseased areas. In 
the course of time the bases of the pustules show an overgrowth of epidermis 
and connective tissue, a hyperplasia very like the appearance of condylomata 
lata of syphilis. The mucous membranes are affected in the same way as is 
the skin. The disease may terminate with pregnancy, but usually it does not. 
The cases reported have all terminated fatally except two, either from an inter- 
current pulmonary affection or in a typhoid state. Treatment is best carried out 
in the continuous bath, the patient eating and sleeping in it. It may be medi- 
cated with creolin or ichthyol. Without this, antiseptic dressing twice daily is 
necessary. Internal medication is useless except in the form of tonics and 
maintenance of nutrition. 

5. Alopecia. — Loss of hair is not a common phenomenon in the pregnant 
state or immediately following it. Of the two periods, it is oftener developed 
post partum than in the course of pregnancy. There is a possibility, however, 
that the fall is noticed only when the hair has become thin. In these cases 
there is no scaling or only as much as one would expect normally. The hairs 
are loosened in their sheaths and come away readily on traction. They lose 
their sheen, apparently take on a darker color, and break off or split at their 
ends. The fall is general, but the temporal regions are usually chiefly affected. 
It is rare that any part is completely denuded. There are almost always a 
few hairs scattered even over the baldest spots. 

Etiology. — It would seem probable that this affection is to be classed with 
the alopecias of prolonged fevers. If so, it is a nutritional disturbance in the 
hair papillae, doubtless toxemic in origin. A noteworthy fact in this connection 
is that the women, in my experience, have all been neurotic. 

Diagnosis. — Alopecia areata occurs in scattered round spots which are 
perfectly denuded or show only a few short shafts shaped like an exclamation 
point. The alopecia of syphilis has the same patchy character and is asso- 
ciated with other symptoms of the disease — eruption, mucous patches, and 
lymphadenitis. Seborrheic alopecia is always accompanied by dandruff, the 
scales are thick, greasy, and yellow, or gray and less thick. Its duration is 
greater than that of pregnancy and the hairs are apt to show a beginning of 
graying. 

Treatment. — The women usually require iron and strychnin, hydrotherapy 
and forced feeding. Locally, something can be done in the way of prevention 
by careful attention to the scalp hygiene during pregnancy. Shampooing 



DISEASES OF THE OSSEOUS SYSTEM. 383 

with tincture of green soap every fortnight and application of a 5 per cent, 
resorcin lotion are sufficient. After full development, as regards the shampoo, 
it is well to warn the patient that she may see a considerable loss at first. If 
there is any scaling, the resorcin lotion should be used two or three times a 
week. A serviceable wash is salicylic acid gr. xx, resorcin one-half drachm, 
oleum ricini one-half drachm, oleum lavandulas ten drops, alcohol one ounce. 
When there is no dandruff, pilocarpin is incomparably the best remedy. It 
cannot very well be used in injection on account of its depressant action, but it 
may be applied to the scalp every day in a one or two per cent, alcoholic lotion. 
The hair should be parted and the wash well rubbed into the roots. If the ex- 
pense is too great, undiluted fluid extract of jaborandi may be substituted, 
but is not nearly so efficacious. Prognosis is always good. 



XVIII. DISEASES OF THE OSSEOUS SYSTEM. 

I. Relaxation of the Pelvic Joints. 2. Inflammation of the Pelvic Joints, j. Osteomalacia. 

4. Rachitis. 

i. Relaxation of the pelvic joints is an exaggerated degree of the normal 
process by which the pelvis is prepared for labor (see page 117). On the other 
hand, it may be caused by a pathological state of the joints, such as inflammation. 
The sequelae of this condition may be suppuration, fluid in the joints, and other 
abnormal conditions. Locomotion may be effectually hindered, and as a rule 
there are pains in these joints, as well as in the thighs and in the lumbar region. 
A firm binder gives great relief and is often a sufficient support for comfortable 
locomotion (Figs. 233 and 234). Rest in bed must occasionally be enjoined; 
the binder should be worn after delivery until the parts have returned to their 
normal condition. I am accustomed to make use of the same type of binder in 
these cases as after the early days of the puerperium (Part VI); a plaster-of- 
Paris bandage is, perhaps, necessary in the more severe cases. 

2. Inflammation of the Pelvic Joints. — In rare instances an inflammatory 
process occurs in connection with the relaxation just mentioned. The symp- 
toms are aggravated, the pain may be severe, and there is swelling over the 
affected joints, with tenderness on pressure. The treatment is the same as for 
simple relaxation, with the addition of anodynes and anodyne applications, 
Cold applications may be of service. 

3. Osteomalacia. — This affection is rare in America, but endemic in Italy, 
Austria, Switzerland, and other portions of Europe. The subjoined account 
is taken largely from Schuchardt's * work on diseases of the bones and joints. 

The affected bones are of a lively red hue, and are either soft and flexible 
or show a high degree of porotic atrophy, a saw cutting through them as if 
they were rotten wood. In the very highest degree the periosteum is trans- 
formed into a sac containing a white, puffy mass which represents the original 
osseous tissue. As a rule, the marrow is unusually reddened, and commonly 
consists of lymph-marrow; in rare instances fat-marrow may be present, the 
color then being yellow. Cystic degeneration often occurs, and is thought to 
be salutary and to denote the resolution of the morbid process. 

The naked-eye deformities in osteomalacia are numerous and characteristic. 
At first, while the patient is able to walk about, the changes are those produced 
by the weight of the body. There is a stronger bend to the neck of the femur. 
* In vol. xxviii of the "Deutsche Chirurgie." 



384 PATHOLOGICAL PREGNANCY. 

The pelvis takes on the characteristic clover-leaf form, the pubic bone becomes 
beak-like, the sacrum is bent toward the pelvic axis, the lumbar vertebras are 
shortened and compressed and biconcave, suggesting the vertebras of fish, etc. 
The base of the skull is elevated. The origins of large muscles, tendons, and 
ligaments often become unduly prominent because of the softness of the bones 
(osteomalacic enlargement of bones). 

The long bones are, at the outset, almost non-participating, but eventually 
exhibit flexure and curvature. In the worst cases these bones become, simply 
amorphous masses of flesh. 

If recovery sets in in these cases, new osseous tissue is formed, the centers 
of the bones being occupied by osseous tubercula or enostoses. 

With regard to the course pursued by puerperal osteomalacia, the disease 
seldom attacks women who live under hygienic requirements. Miserable, 
overworked, and underfed peasants, living in damp and unhealthful surround- 
ings, are the principal victims. Even here certain endemic influences obtain, 
so that Italy and Switzerland take the lead over other countries in morbidity. 

As a rule, multigravidas are attacked by preference. The pelvic bones 
are first affected, and under the influence of the warmth of the bed, rheumatoid 
pains set in. Tenderness over one or both ischial tuberosities is an early symp- 
tom, interfering with sitting. The pains appear wherever softening is in prog- 
ress. The patient loses rapidly in height, even to the extent of a foot or more. 
The joints appear to be involved in a sort of arthritis deformans, and fever 
is occasionally present. Changes in the muscles, not unlike those of progres- 
sive muscular atrophy, often occur. A peculiarity of gait is thought to be due 
to paresis of the ileopsoas muscle. Later on it is found impossible to abduct 
the thigh and eventually, of course, all locomotive efforts become impossible. 
The condition may last for years, with exacerbations and remissions. Par- 
ticular deformities may result from various positions assumed while the patient 
is bed-ridden. In diagnosis this affection has not infrequently been confounded 
with various diseases of the spinal cord. Symptoms of great value in early 
diagnosis are isolated iliopsoas paresis, the diminution in height, and the altera- 
tion in the measurement of the conjugate. With regard to treatment and prog- 
nosis, Winckel has seen spontaneous recovery. Tonic and hygienic measures 
of all sorts are prescribed, and prolonged treatment with phosphorus appears 
to give excellent results. Cod-liver oil is usually given as a synergist. The fact 
that the pelvic bones have undergone softening and extensibility, despite the 
pelvic narrowing, does not favor the expulsion of the child. According to Litz- 
mann, there occurred in 72 osteomalacic women only 21 natural labors. In 16 
cases the fetal head was perforated; in 40, Cassarean section was performed, 
artificial premature delivery was the management in 2 cases and symphyseotomy 
in one. Seven women had rupture of the uterus, and four died undelivered. 
Porro employed his utero-ovarian amputation in these cases with much success. 
Fochier, of Lyons, and Levy, of Copenhagen, who have done many Porro opera- 
tions in osteomalacic labors, came to the conclusion that the castration incidental 
to this form of intervention has a salutary effect upon the disease. In 1886 
Fehling began to test this theory by the performance of simple castration in 
these cases, with an astonishing degree of success, and the practice has become 
general. Even after the first day from the time of operation the pains abate and 
the tenderness becomes less marked. In a small number of cases no benefit is 
received from the operation, which should not be performed until all other 
measures have failed. (See Section on Osteomalacic Pelvis, Part V.) 

4. Rachitis. — (See Pelvic Deformity, Part V.) 



ABORTION, IMMATURE AND PREMATURE LABOR. 



385 



XIX. THE PREMATURE INTERRUPTION OF PREGNANCY; 

ABORTION; IMMATURE LABOR OR MISCARRIAGE; 

PREMATURE LABOR. 

Classification and Definitions. — An abortion is a termination of pregnancy 
before the placenta is formed; namely, in the first twelve weeks or three months. 
A miscarriage, or "partus immaturus" is the termination of gestation at any 
time from the end of the twelfth week, or third month, to the end of the twenty- 
seventh week, or six and three-fourths lunar months. A premature labor, or 

"partus prematurus," is the premature 
interruption of pregnancy, occurring 
at and after the twenty-eighth week, or 
seventh lunar month, and before the 



Serotina 




Decidua vera. 

Decidua sero- 
tina. 

Decidua re- 
flexa. 

Chorion. 

Amnion. 

Liquor antnii. 

Embryo. 



Fig. 483. — First Type of Abortion. 
Retention of remnants of decidua only. 
So-called "complete abortion." 




Chorion. 
Amnion. 
Liquor amnii. 
Embryo. 



Fig. 484. — Second Type of Abortion. 
Retention of decidual. Incomplete abor- 
tion. 



thirty-eighth week, or nine and a half lunar months. I look upon the classi- 
fication which groups under the term abortion all cases occurring within the 
first twenty-seven weeks of gestation as also justifiable, because before this 
time practically no regard need be paid to the life of the fetus, which may 
be regarded as lost. I would, then, speak of early abortions in the first 
twelve weeks, and late abortions from the end of the twelfth week to the end 
of twenty-seven and a half weeks. Most of the German text-books on ob- 
25 



386 



PATHOLOGICAL PREGNANCY. 



stetrics look upon the separation of abortion and immature labor as unjustifiable, 
and consider the period of viability, at the end of the seventh month, to be the 
only admissible point of division. Most of the French text -books understand 
the term "avortement" to extend to the end of the seventh lunar month of 
gestation. According to this classification, abortions are pregnancies ter- 
minated in the first six and three-fourths months, or the first twenty-seven 
weeks; a further division is made into early abortions in the first twelve 
weeks, and late abortions, falling within the period from the beginning of 
the fourth to the end of the seventh lunar month; the term premature labor 



Placenta. 



Serotina. 




Fig. 485. — Third Type of Abortion. 
Retention of deciduas and chorion. 
Incomplete abortion. 



Fig. 486. — Fourth Type of Abortiox. 
Retention of deciduae, chorion, rudi- 
mentary placenta and amnion. In- 
complete abortion. 



covers the remaining cases from the twenty-eighth to the thirty-eighth week. 
For fear of confusion of terms already generally accepted in this country, I 
hesitate to adopt this latter classification here. The period of viability is the 
time when the fetus can live apart from its mother, the turning-point between 
partus immaturus and prematurus ; and this limit is generally placed at the 
end of the seventh lunar month, or twenty-eighth week, from conception. 
We must not lose sight of the facts, however, that, on the one hand, fetuses 
may not be viable until after this estimated date, because the calculation of 
the duration of pregnancy is uncertain; and, on the other hand, that, excep- 
tionally, children born previous to the calculated twenty-eighth week may 



ABORTION, IMMATURE AND PREMATURE LABOR. 



387 




Fig. 487. — Incomplete Miscarriage 
at the Fifteenth Week. The 
amnion, covered by shreds of cho- 
rion and decidua, was expelled un- 
ruptured. Most of the chorion and 
decidua, and the entire placenta, 
were retained in the uterine cavity, 
(f natural size). — (Author's case.) 



live. There is to-day no doubt * that many children born before the end 
of the seventh lunar month may be saved by the use of the couveuse and of 
gavage, and that a certain proportion of the children born at the twenty-seventh, 
twenty-sixth, twenty-fifth, or even twenty-fourth week of gestation can be 
preserved. Budin claims to have saved 30 
per cent, at the twenty-fourth week. A 
complete abortion is one in which the fetus 
and membranes are cast off intact; an in- 
complete abortion is one in which the fetus is 
born, and the embryonic membranes, all or 
in part, remain in the uterus; an abortion is 
inevitable when such hemorrhage occurs, and 
the ovum descends into the lower part of the 
uterus, or when part of the chorion or liquor 
amnii escapes ; a concealed abortion is one in 
which the embryo perishes, but is not ex- 
pelled; in missed abortion the embryo dies, 
symptoms of threatened abortion occur and 
subside, and the ovum remains in the uterus 
for a varying length of time; spontaneous 
abortions are those which occur naturally, 
not being caused by artificial interference of 
any kind; induced abortion is one which is 

caused intentionally and artificially, for strictly medical reasons; criminal abor- 
tion, or feticide, signifies the act of attempting to procure an emptying of the 
uterus for other than strictly medical reasons, and the term holds good, whether 

the attempt proves successful or fails ; 
The terms slow and retarded abortions 
explain themselves. Therapeutic abor- 
tion is one which is performed for 
strictly medical reasons. 

Pathology. — The Ovum: In only 
exceptional instances does the entire 
ovum intact, with the vera, pass out 
in the first months. One can repeat- 
edly, in curetting cases of apparently 
complete abortion, obtain pieces of 
tissue which the microscope proves 
to be decidua (Fig. 48). It is com- 
mon for the reflexa to be ruptured by 
the descent of the ovum, leaving the 
former, with the vera and serotina, to 
pass away during the puerperium, or 
to be removed by operation. Again, 
we infrequently see the chorion as well 
as the reflexa ruptured, the cord being 
torn from the placenta, and the fetus, 
enclosed in the amnion, with liquor 
amnii, alone expelled (Fig. 104) . I have several specimens of this variety of abor- 
tion, and it has been observed as late as the sixteenth week (Fig. 104). A rare 
modification of this last process is shown when decidua vera, reflexa, and chorion 
*Ahlfeld; "Arch. f. Gynak.," vin, p. 194. 




Fig. 488. — Blood Mole Changing into a 
Flesh Mole, w, White area in the blood 
mass; b, blood extravasation into rudi- 
mentary placenta ; rs, outer rough surface 
of mole; o, ovum cavity with amnion cut 
open. — (Bumm.) 



388 



PATHOLOGICAL PREGNANCY. 



are torn away, leaving the placenta (serotina) fitted like a cap on the amnion 
(Fig. 487). The further gestation has advanced beyond the twelfth week, the 
more closely does the interrupted pregnancy resemble labor at term. Moles: 
In many cases the embryo dies early, but abortion does not occur at once; the 
result is a uterine mole. This formation consists of a sac with thick walls which 
are at first red, but which later become of a lighter hue (Fig. 488). The cavity 
is irregular and corresponds to the amnion; the entire space between the amnion 
and the external surface is bound by chorion within and decidua without, 
and is filled with blood, thus forming "blood moles" and "flesh moles" 




f 




Fig. 489. — Abortion at the Eighth 
Week. Separation of the (dv) decidua 
vera and (s) serotina from the uterine 
wall. Partial descent of the entire 
ovum; hemorrhage into the decidua re- 
fiexa; beginning dilatation of the (i) in- 
ternal os. e, External os; lo, lower end 
of ovum. 




Fig. 490. — Abortion at the Eighth 
Week. The ovum, entirely separated 
from the uterine wall, rests in the dilated 
cervical canal, the (<?) external os alone 
preventing its escape into the vagina (v) 
— so-called "cervical abortion." u, 
Uterine cavity; i, internal os; r, rudi- 
mentary placenta; dr, decidua reflexa; 
d, decidua vera; e, external os;v, vagina; 
i. internal os. 



(Fig. 488). In many cases the fetus entirely disappears. If the fetus has not 
disappeared, it may retain a fresh appearance, despite the fact that it may 
have been dead many days; or maceration may take place, the mass becom- 
ing soft, flabby, and dark red; the fetal surface is covered with blebs; all the 
parenchymatous organs degenerate; the brain is fluid and the skull collapses. 
Such fetuses are not infected, and are sometimes spoken of as foetus sangui- 
nolentus. In other cases the fetus becomes dry or mummified, and may remain 
in the uterus for years (Figs. 454 and 455)- In rare cases a second pregnancy 
may take place ; in other instances the mummified fetus becomes calcified, and 



ABORTION, IMMATURE AND PREMATURE LABOR. 



389 



'is then termed foetus lithopcedion (Fig. 456). Periovular Hemorrhage; Pla- 
cental Apoplexy : Up to the end of the second month there is a marked ten- 
dency for the blood to spread out and form a thin layer |to i| inches (4 to 
30 mm.) in thickness, upon the surface of the chorion, causing the ovum to re- 
semble a piece of flesh, bluish or blackish in color. The enveloping mem- 
branes are seldom ruptured, and since this collection of blood is often larger 
than the ovum itself, it goes to show that the ovum is not the source of this 
hemorrhage. But later, in the third and fourth months, this tendency 
decreases, and the blood is apt to collect in a limited space in the placenta, 




Fig. 491. — Abortion at the Twelfth 
Week. First stage. Beginning separa- 
tion of the placenta and dilatation of the 
cervix, d, Decidua vera; w , uterine cav- 
ity; dc, dilated upper portion of cervix; 
e, external os; p, attached portion of 
placenta; ds, decidua serotina; ps, area 
of placental separation; o, cavity of 
ovum; i, internal os; r, origin of reflexa. 




Fig. 492. — Abortion at the Twelfth 
Week. Second stage, p, Separation 
of the placenta except at its upper por- 
tion; b, beginning separation of the de- 
cidua vera, cervix dilated and contains 
the lower pole of the ovum; u, uterine 
cavity; c, cavity of ovum; a, attached 
portion of placenta; i, internal os; br, 
blood-injected reflexa; e, external os. 



forming placental apoplexies. This latter tendency increases with the advance 
of pregnancy (Figs. 491 and 492). 

Frequency. — For many reasons exact figures as to the frequency of pre- 
maturely interrupted pregnancies are difficult to obtain. During the first 
eight weeks, undoubtedly, many interruptions of pregnancy pass unnoticed, 
and later in pregnancy very few such patients enter maternities, and many do not 
come to the notice of private physicians or of dispensary hospital services. 
I have recently made an exhaustive study of the premature interruption 
of pregnancy occurring among ten thousand cases of labor treated in a dispen- 
sary or outdoor service, in New York city. In favor of a greater accuracy 
of these statistics is the fact that all of the 635 cases of interrupted pregnancy 
were outdoor or dispensary cases, and patients under such circumstances are 



390 



PATHOLOGICAL PREGNANCY. 



more likely to seek aid under their own roof than to apply for admission to a 
general or maternity hospital. Among 10,000 cases of labor I found 635 pre- 
mature interruptions; namely, 242 abortions, 175 miscarriages or immature 
labors, and 218 premature labors. The relative frequency, therefore, was one 
abortion in every 41.3 labors; one miscarriage or immature labor in every 57.1 
labors; and one premature labor in every 45.8 labors. In other words, there 

was either an abortion, a miscarriage, or 
a premature labor once in every 15.7 
labors. 

Age of Patients. — In making out the 
percentages of the frequency of inter- 
rupted pregnancy, in different five-year 
groups or ages, I obtained the following 
results, namely: nineteen years and 
under, the percentage of interruption 
was 3.52 per cent.; twenty to twenty- 
four years, 5.01 per cent.; twenty-five to 
twenty-nine years, 6.02 per cent. ; thirty 
to thirty-four years, 7.33 per cent.; 
thirty-five to thirty-nine years, 10.48 
per cent. ; forty to forty-four years, 18.94 
per cent. From these studies I draw 
the conclusion that the smallest prob- 
ability of an untimely interruption of 
pregnancy is before the twenty-fifth 
year, and that the greatest probability 
is after the fortieth year. 

Parity. — In the table on page 392 has 
been arranged the relative frequency of 
cases according to the number of pre- 
ceding labors (-para), added to the num- 
ber of mature labors, under primiparae, 
pluriparae (pluriparae II, III, IV, and 
Vparae), and multiparas. 

The table shows that in primigra- 
vidae, gestation is least endangered in 
the first months of pregnancy, and that 
the frequency of interruption in primi- 
gravidae increases with the further ad- 
vance of pregnancy. The table also 
shows that in pluriparae and multiparas 
the relation is reversed; the majority 
of interruptions among these occurring 




Fig. 493. — Abortion at the Twelfth 
Week. Third stage. The ovum, sepa- 
rated and expelled from the uterine 
cavity (uc), lies partly in the cervical 
canal and partly in the upper third of 
the vagina. A portion of the decidua 
vera (d) still remains behind in the uter- 
ine cavity above the internal os (i). 
c, Cavity of ovum; o, lower pole of 
ovum; p, placenta; e, external os; v, va- 
ginal wall; b, blood-clots in the cavity 
or ovum. 



in the first months of pregnancy, and 
that the frequency of interruption now decreases with the further advance 
of gestation. The greater frequency of uterine disease in multiparas, and 
the large number of preceding labors, some of them undoubtedly anomalous, 
are a sufficient explanation of the greater frequency of abortion than of pre- 
mature labor in multiparas. With every additional interruption of pregnancy 
the length of gestation recedes, so that after the occurrence of a premature labor 
there ensue first miscarriages and finally abortions. The uterus, therefore, 
in the presence of uterine disease, becomes ever less tolerant of subsequent 



ABORTION, IMMATURE AND PREMATURE LABOR. 



391 



pregnancies, and expels its contents earlier, in proportion to the number of 
preceding interruptions of pregnancy, thus emphasizing Winckel's statement 
that "the longer existence of uterine disease leads to ever earlier interrup- 
tion of pregnancy." 

TABLE OF PARA. 



Para. 


ABORTIONS. , CAR ^ ESi 


Premature 
Labors. 


Total In- 
terrupted 
Pregnan- 
cies. 


Total Full 
Term. 


Total In- 
terrupted 
and Full 
Term. 


Primiparae 

Pluriparae* 

Multiparae 

Unknown 


29 

120 

79 

14 


1 
22 71 122 2,009 

94 97 3 11 5.202 
49 46 174 2,047* 
10 4 28 107 


2,131 
5.513 
2,221 

135 


Total 


242 175 218 635 9,365 


10,000 



Month 0} Gestation. — I found in the 635 cases, as will be seen in the table 
on page 392, that there is a marked tendency for gestation to terminate in the 
third month, 23.91 per cent, occurring at that time; in the fourth month, 11. 18 
per cent.; in the fifth month, 6.93 per cent.; in the sixth month only the slight 
liability of 6.15 per cent.; a slight increase in the seventh month to 9.60 per 
cent. ; and in the eighth and ninth months the frequency again goes up to 
12.63 per cent, and 12.25 per • 

cent, respectively. 

Etiology. — The causes of 
interrupted pregnancy may 
be placed in three classes, 
and named in the order of 
their frequency (1) maternal 
causes; (2) causes in the 
ovum, embryo, and fetus; 
(3) paternal causes. 

1 . The maternal causes are 
divisible into the systemic and 
the local. The systemic causes 
include obesity, marriages of 
consanguinity, pregnancies in 
rapid succession, very hot 
climates, and very high alti- 
tudes. Poisons, such as syph- 
ilis, which holds the first place, 
are a frequent cause; e.g., 
malaria ; large doses of arsenic 
in skin diseases ; lead and mer- 
cury in factories ; the abuse of 
drugs known as oxytocics 

(ergot, cottonroot, quinin, aloes, juniper, black hellebore, tansy, pennyroyal, can- 
tharides, any of these rarely disturb a healthy ovum in a healthy uterus) ; and the 
toxemia of kidney insufficiency. The effects of maternal toxemia on the fetus 
depend not on the intensity of the poison, but on the power it has to excite uterine 
irritability. In some cases this irritability is so easily aroused that a slight degree 
of toxemia will be sufficient to excite it, entailing the expulsion of the fetus before 

* Pluriparae in II, III, IV, Vparae. 




Fig. 494. — Flesh Mole. (Author's Case.) 



392 



PATHOLOGICAL PREGNANCY. 



sufficient time has elapsed for it to perish from toxemia; while in others the fetus 
will suffer only from the prolonged effect of the poison, the uterus having so great 
a resistant power against the toxin. In the latter condition the irritability of the 
uterus has a mechanical, and not a toxic origin. The non-elimination of car- 
bonic acid gas, in diseases of the heart, lungs, and liver; or violent mental shock 
or excitement, may interrupt pregnancy; but how this latter acts is not known. 
Anemia, tuberculosis, infectious diseases with high temperature, especially 
when the latter is suddenly developed, are also causes. The local causes include 
all causes of acute or chronic, pelvic congestion, such as malformations and 
malpositions of the uterus, especially retro-displacements; metritis, endome- 
tritis, salpingitis, tumors, malignant disease; excesses in sexual intercourse in 
the newly married; traumatisms, as a blow or a fall; criminal use of instru- 
ments; all causes of obstructed venous return. Perhaps the most important is 
previous uterine disease, such as endometritis, which is quite common. 



Week. 


Month. 


Number of 
Cases. 


Percentage of 
Interruption. 




4 
6 


I. 
1* 






10 Not Noted. 


8 


II. 


61 


9.61% ) 




IO 


2* 


40 


6.29% \ 


232 Abortions. 


12 


III. 


131 


20.63% J 




14 


3* 


21 


3.3i% \ 




16 


IV. 


62 


9.76% 




18 


Ah 


9 


1.42% f 




20 


V. 


35 


5-5i% 


175 Miscarriages. 


22 


5i 


9 


1.42% \ 




24 


VI. 


28 


4.42% J 




26 


6* 


11 


T-'lZfo ' 




28 


VII. 


47 


7.40% \ 




30 


7* 


14 


2.20% J 




32 

34 


VIII. 


65 
15 


10.26% f 
2.37% ( 


218 Premature Labors. 


36 


IX. 


50 


7.99% \ 




38 


9* 


27 


4.26% / 
Total 


635 Interrupted Pregnancies. 



2 . The causes in the ovum and embryo are many of them secondary to morbid 
conditions in the mother, but at the same time are direct causes of interrupted 
pregnancy. The most frequent are those which interfere with the nutrition 
or cause the death of the embryo or fetus, and include decidual and placental 
syphilis, inflammations, and low situations of the placenta. Less frequent 
causes are other diseases and anomalies of the decidua, chorion, amnion, liquor 
amnii, placenta, umbilical cord, and the fetus itself, which produce the same 
result (see pages 199 to 257). As a rule, the fetus after death acts like a foreign 
body in the uterus, although now and then it is retained for some time, but 
rarely over two weeks. 

3. Chief among the paternal causes is syphilis, resulting in syphilitic sper- 
matozoa, syphilitic changes in the placenta and fetus, occurring in some instances 
with no sign of the disease in the mother; tuberculosis; extreme youth or old 
age; great constitutional depression, or exhaustion from any cause. 

Relative Frequency. — The principal causes in the order of their frequency 
are (1) diseased endometrium; (2) retro-displacements of the uterus, with 



ABORTION, IMMATURE AND PREMATURE LABOR. 



393 



or without adhesions; (3) syphilis; (4) kidney insufficiency, toxemia; (5) 
criminal interference; (6) low insertion of the placenta. 

Recurrent Interruptions. — The most frequent causes of instances of repeated 
interruptions in the same individual are (1) disease of the endometrium; (2) 
retro-displacements; (3) syphilis; (4) toxemia. In some instances the cause 
is so pronounced and permanent, especially in cases of chronic pelvic inflam- 
mations, that a tendency to abort at the same period in successive pregnancies 
exists, thus giving rise to the term "the abortion habit." Some abortions 
occur without any assignable cause, or from such slight cause that the accident 
has been ascribed to an " irritable 

uterus." As has been frequently p. 

pointed out by different observers 
(Winckel), a striking feature in the 
study of the etiology is the number 
of preceding premature interrup- 
tions of pregnancy. 

In 407 abortions and miscar- 
riages I found 38 women, or 9.1 per 
cent., who had experienced pre- 
vious abortions or miscarriages ; 
103, or 24.7 per cent., who had ex- 
perienced previous premature spon- 
taneous labors; and 141, or 34 per 
cent., who had experienced pre- 
vious interrupted pregnancies. 
Among 218 spontaneous prema- 
ture labors, there were 15 women, 
or 6.9 per cent., who had experi- 
enced previous abortions or mis- 
carriages; 44, or 20.2 per cent., who 
had experienced previous prema- 
ture labors; and 59, or 26 percent., 
who had experienced previous in- 
terrupted pregnancies. The most 
striking fact shown in the foregoing 
figures is the large number of pre- 
vious untimely interruptions of 
pregnancy; for, as the figures 
prove, among 407 women who 

aborted and miscarried, 141, or 34 per cent., suffered from previous premature 
interruptions of pregnancy; and among the 218 cases of premature labor, 59, or 
26 per cent., had experienced previous untimely interruptions of pregnancy. 

Symptoms. — The symptoms of interrupted pregnancy vary with the different 
months of gestation; but usually premonitory symptoms of pelvic congestion 
occur, and the characteristic symptoms follow — namely, hemorrhage, pain, 
dilatation of the os, descent and discharge of the ovum, embryo, or fetus. 
Great variations in symptoms occur between the first and thirty-eighth weeks 
of gestation. In the early weeks the clinical phenomena often resemble merely 
an exaggerated menstrual epoch, while at the eighth month all the phenomena 
of labor at term are present. A marked prodrome of spontaneous abortion and 
miscarriage is a tendency to syncope, and it should be remembered that abortions 
or miscarriages occurring suddenly are rarely accidental or spontaneous. 

Clinical Phenomena. — 1. Abortion: In abortion — namely, before the be- 




Fig. 495. — Incomplete Abortion. Cervix 
Readily Dilatable, p, Retained placenta; 
b, blood-clot; 5, separated vera; d, decidua 
vera: h, hemorrhagic decidua vera. 



394 PATHOLOGICAL PREGNANCY. 

ginning of the fourth month — the clinical picture presented by the emptying 
of the uterus is usually altogether different from that of an interrupted preg- 
nancy occurring subsequently. During the first three months the ovum is 
expelled as a whole, or broken up, with more or less profuse hemorrhage; hence 
it is that usually but a single stage of labor can be recognized; while after the 
third month the course of labor corresponds more and more with parturition 
at term, and in most instances three stages of labor can be distinctly differen- 
tiated. In the first six weeks we most frequently have "ovular abortions," 
so called because the embryo is still indistinguishable, the ovum being dis- 
charged intact (see Pathology) and unruptured, with marked hemorrhage 
but with little or no pain; the time of occurrence is apt to correspond with 
the menstrual epoch, and the little pain and backache present are attributed 
to menstruation and to the discharge of clots through a contracted cervix, the 
ovum passing away unnoticed. From the sixth to the twelfth week, " embry- 
onal abortions " are more common, so called because the human form has not 
yet been fully assumed. In these we observe prodromal symptoms of pelvic 
congestion; the pain and hemorrhage are more severe; there is first an escape 
of the embryo, followed after a varying period, which resembles somewhat 
the prolonged third stage at term, by the retained decidua, chorion, amnion, 
and rudimentary placenta. The occurrence of abortion at this time is often 
preceded and accompanied by active symptoms, such as syncope, nausea, slight 
rigors, backache, increased vaginal secretion, frequency of micturition, thirst, 
pallor, and, in some cases, nervous symptoms. Later the pain in the back 
increases, and is perhaps attended with a feeling of intrapelvic pressure; free 
hemorrhage occurs, large clots are passed from time to time, and finally the 
ovum is expelled intact or in portions. For the symptoms of threatened, 
inevitable, complete, incomplete, neglected, concealed, missed, and criminal 
abortions, see Diagnosis. 

2. Miscarriage or immature labor: As gestation advances through the fourth, 
fifth, sixth, and seventh months, we find the clinical phenomena of interruptions 
becoming more and more like labor at term. Three stages of labor can now 
be differentiated; the uterine contractions are more marked; severe voluntary 
bearing-down efforts appear; there is less and less hemorrhage in the first 
stage, and more at the end of the second and during the third; there is rupture 
of the membranes and a gush of liquor amnii; occasionally the ovum is dis- 
charged intact in the fourth, fifth, and even sixth months — fetus, liquor amnii, 
membranes, and placenta being discharged in one mass. The distinguishing 
clinical characteristics of interrupted pregnancy, at this period, are retention 
of the placenta, which is completely or partially adherent, and profuse hemor- 
rhage in the third stage. 

3. Premature labor: In comparing the course of the process in immature and 
premature labors, we find that, clinically, the most important distinguishing 
feature between the two is the length of the third stage of labor. After the 
end of the twenty-eighth week the third stage of labor may differ in no way 
from the third stage at full term, while before the seventh month the third 
stage may continue days and weeks, unless its course is artificially terminated. 

Duration. — The duration of interrupted pregnancy varies. The process 
may be quite rapid, or days or weeks may elapse. The average duration of 
abortions may be stated as between twenty-four and thirty-six hours. Abortion 
may be instantaneous. This is rare, and may result from a fall, which causes 
the immediate expulsion of the ovum, with hemorrhage. The time may 
equal that of labor, as more frequently happens, and hemorrhage and uterine 
contractions are the two essential features, either one or the other predomi- 



ABORTION, IMMATURE AND PREMATURE LABOR. 395 

nating, or both being of about equal importance. Slow abortion is yet more 
frequent than the two above types. The causes are weak uterine contractions 
and undue resistance of the cervix, or more often retention of the placenta with 
slow detachment. The latter feature depends on the extent of surface oc- 
cupied by the chorionic villi. Placental retention occurs about fifteen times 
in a hundred cases. Retarded abortion is occasionally caused by the reten- 
tion of the ovum in the cavity of the cervix, the "cervical abortion" of 
Schroeder (Fig. 49°)- 

Diagnosis. — The diagnosis of any variety of interrupted pregnancy, abor- 
tion, miscarriage, or premature labor depends upon five prominent factors: 
namely, (i) the diagnosis of pregnancy; (2) pain (uterine contractions); (3) 
hemorrhage; (4) dilatation of the cervix; (5) descent of the ovum, embryo, 
or fetus into the os. 

1. Abortion. — The same difficulty often attends the diagnosis of an abortion 
in the early weeks, as the positive diagnosis of pregnancy during the same 
time. If the ovum has entered the internal os and can be recognized by the 
examining finger, no doubt will exist; indeed, in most cases the evidence of 
profuse hemorrhage and dilatation of the cervix will be sufficient. The ovum, 
if intact, can be distinguished by the fact that it becomes tense and is pressed 
downward during a pain. Clots should be carefully washed in water, in 
order that portions of deciduae or fringe-like chorionic tissue may be recog- 
nized. The possible existence of extrauterine pregnancy should not be for- 
gotten, however, for in this condition the expulsion of decidua may occur. 
The possibility of hemorrhage from cancer of the cervix or other morbid con- 
ditions, already described, should also be remembered. The physical signs 
do not differ materially in ovular and embryonic abortions. At first, on vaginal 
and bimanual examination, we find the cervix softer than would be expected; 
rather profuse hemorrhage from the os; the body of the uterus either hard 
from tetanic contraction or alternately hard and soft. Later, after several 
hours perhaps, dilatation of the os is observed; the ovum descends and may 
be palpated through the os with the examining finger, and perhaps there is 
effacement of the angle of anteflexion which exists early in pregnancy between 
the cervix and body (Tarnier's sign). This sign of inevitable abortion, de- 
scribed by Tarnier, is by no means constantly present. It is most important, 
at this time, to be able to distinguish with the examining finger between the 
ovum and a blood-clot situated just within the os. In threatened abortion 
the clinical picture shows a hemorrhage bright in color, free from clots, inter- 
mittent in character, fairly persistent, and moderate in amount; there is 
little pain or none at all; the os is somewhat dilated, but does not allow 
the passage of the finger; the uterus is soft, anteflexed, and intermittent con- 
tractions are infrequent. The symptoms may subside, or persist and result 
in a complete or an incomplete abortion. As long as a chance of the subsidence 
of the symptoms exists, the abortion is said to be threatened. In inevitable 
abortion the hemorrhage is persistent, increasing in amount, and contains clots 
and fragments of the ovum and liquor amnii; pain and uterine contractions 
are present and increase in severity; the os is dilated and admits the examining 
finger, which palpates the ovum within the os; the uterus is alternately soft 
and hard, or is tetanically contracted. The ovum perishes and is expelled, 
or occasionally is retained, as in missed abortion. In complete abortion there 
is practically no hemorrhage; pain is absent; a slight discharge resembling 
lochia and containing small shreds of decidua is present; the os is closed; the 
uterus is hard and well contracted, and involution is progressing normally; 
there is a rapid subsidence of all the probable signs of pregnancy. The exami- 



396 PATHOLOGICAL PREGNANCY. 

nation of the mass that has been expelled, which should always be made, will 
give the best results if the clots and blood are removed by washing in clean 
water. In the case of complete abortion the decidual will be seen closely em- 
bracing the mass, since the line of separation is in the spongy part. In order 
to detect any imperfection in the membranes, it is well to float them upon 
the surface of the water, when their structure will be clearly seen. In incom- 
plete abortion hemorrhage is persistent, but varies in amount; it is at first bright 
in color, later dark brown, thick, and offensive; attacks of intermittent uterine 
pain, resembling "after-pains," are present; the lochia may contain shreds 
of decidua, amnion, or rudimentary placenta; the os readily admits the finger, 
and decidua, membrane, pieces of placenta, and blood-clots are found in the 
uterine cavity; the uterus remains persistently large and soft; involution is 
absent, and, with the exception of the enlargement of the uterus, the probable 
signs of pregnancy disappear. To sum up : if the pain and discharge continue 
from time to time, if the uterus is soft and boggy, if the os remains' patulous, 
and if the examining finger detects retained portions of the ovum, the abortion 
is incomplete. In neglected abortion the clinical picture is the same as in incom- 
plete abortion, with the addition of the symptoms of local and general septic 
processes (see Fever). In concealed abortion — namely, in cases in which the 
embryo perishes but is not expelled — the clinical phenomena are absence 
of hemorrhage and of pain; no discharge; the cervix is soft; the os is closed, 
but may admit the finger with firm pressure; the uterus, soft, flabby, has lost 
the usual resiliency of pregnancy, and fails to increase in size, rather diminishing; 
the signs of pregnancy, aside from the enlarged uterus, subside. In missed 
abortion there are all the clinical signs of threatened abortion, with a subsidence 
of the same, followed by those of either concealed or neglected abortion. In 
induced or criminal abortions the clinical phenomena may not differ from those 
of spontaneous, complete, or incomplete abortions. 

2. Miscarriage. — In the second third of gestation the diagnosis of either 
pregnancy or a threatened interruption becomes much easier, because the 
signs of pregnancy are all more marked, the symptoms of miscarriage are of 
greater severity than those of abortion, fetal parts and uterine contractions 
are readily recognized, and there are the formation of a bag of membranes and 
the escape of liquor amnii. 

3. Premature Labor. — The diagnosis of premature labor becomes practi- 
cally the diagnosis of labor at term. (See page 526.) 

Differential Diagnosis. — Abortion and miscarriage are to be differentiated 
from menorrhagia, metrorrhagia, dysmenorrhea, and ectopic gestation. Differ- 
entiation is also called for between threatened and inevitable, complete and 
incomplete abortion, and between an ovum and a blood-clot. It is a matter 
of importance to distinguish between threatened and inevitable abortion, since 
the treatment of the latter condition is radically different from that of the 
former. In threatened abortion the discharge is usually of a bright red color 
and free from clots, whereas in inevitable abortion large clots and perhaps por- 
tions of ovum may be present. In threatened abortion there is little or no pain, 
while in inevitable abortion, especially after the first month, the pain may be con- 
siderable. Instances have been recorded in which the os has admitted two fin- 
gers, but has subsequently closed and the symptoms have disappeared ; in which 
fragments of decidua have been expelled from the uterus and yet the case has 
gone on to term; but in general it may be said that if there are much pain and 
profuse hemorrhage, if the cervix admits the finger, and if the ovum can be felt, 
there is little doubt as to the result. Tarnier's sign has already been mentioned 
(page 395). To distinguish between a complete and an incomplete abortion is also 



ABORTION, IMMATURE AND PREMATURE LABOR. 397 

important, with reference to treatment, in order to determine whether the uterine 
contents have been wholly or only partly expelled. The discharge of an intact 
ovum will, of course, settle the question. If the hemorrhage and pain cease, if 
the os is closed, and if the uterus, although still large, is firmly contracted, and 
there is a disappearance of the signs of pregnancy, especially the milk secretion, 
the abortion is probably complete. In order to differentiate an ovum from a 
blood-clot by the palpating finger, Holl's sign may be of service, (a) During 
a pain, caused by uterine contraction, the ovum, increased in size, smooth 
and tense, advances, while a blood-clot does not become tense, nor does it 
advance, (b) The ovum presents a tense, resilient, and convex surface, while 
the blood-clot is cone-shaped, apex downward, and non-elastic, (c) If pressure 
is exerted on the fundus, in case the mass is an ovum, motion is not transmitted 
to it as a whole, on account of its resiliency, while the blood-clot would be 
moved en masse, on account of its solidity. 

Prognosis. — Mortality: Among the 242 cases of abortion studied there were 
no deaths from any cause; among the 175 cases of miscarriage, one death from 
placenta praevia and ruptured uterus occurred; and in 175 spontaneous pre- 
mature labors there were four deaths, — one from placenta praevia and hemor- 
rhage, one from sepsis and bronchopneumonia, two from nephritis and eclamp- 
sia. These cases were all cared for in their own homes. The prognosis of 
spontaneous interruptions is good, under intelligent treatment, and when the 
cause of the interruption is not in itself a menace to life; such as high tempera- 
ture from an acute general disease, placenta praevia, nephritis, or eclampsia. In 
criminal interruptions, on the other hand, the prognosis is bad, by reason of 
the unskilfulness of the procedure admitting air and septic matter into the 
uterus, the secrecy surrounding the affair, and the accompanying moral shock. 
In neglected or improperly treated cases the mother is exposed to the dangers 
of immediate and late septic infection, of hemorrhage, of endometritis, and 
to a long train of remote evils, including the liability to subsequent abortions. 

The immediate dangers of interrupted pregnancy are: (1) hemorrhage; (2) 
retention of an adherent placenta; (3) sepsis; (4) tetanus; (5) perforation of 
the uterus with a curette. 

1. Hemorrhage. This complication causes alarm only when it is present 
in an extreme degree. It is the general symptoms resulting which are especially 
to be feared; namely, the tendency to syncope, disturbances of the special 
senses, etc. Hemorrhage predisposes to septicemia, but in itself is not often 
fatal. Persistent hemorrhage, though slight, induces a condition of weakness, 
strongly predisposing to infection later. Hemorrhage in abortion, as a promi- 
nent symptom in the early stages of the 242 cases studied, occurred in 85.57 
per cent., thus agreeing with what has already been stated regarding the fre- 
quency of hemorrhage at the outset of abortion cases proper. Of these 242 
cases, 214 were subjected to curettage, shortly after being seen, and in only 
one case was there subsequent hemorrhage. In the 175 miscarriage cases, 
hemorrhage as a prominent symptom before or during labor occurred in 66.29 
per cent, of cases; in of these 175 cases were subjected to curettage shortly 
after being seen, and subsequent hemorrhage took place in five cases. In 
the 218 cases of spontaneous premature labor, hemorrhage before or during 
labor occurred in 6.42 per cent., and after delivery in four cases. Eight of 
these hemorrhage cases were the subject of placenta praevia. 

2. Retention of adherent placenta, which demands an expression, a digital 
or manual removal, or a curettage after removal, is common in the fourth 
and fifth months, and becomes less so as full term is approached (Fig. 495). 



398 



PATHOLOGICAL PREGNANCY. 



3. Septic infection. This may be due to decomposition of retained pla- 
centa, or to faulty asepsis and antisepsis in the technique of the treatment. 
The pulse usually "gives the first signal, which is followed by fever, rigors, 
suppression or putridity of the lochia, etc. Death may come quickly or 
slowly, or by care it may be warded off, though there may be left behind lesions 
of the uterus and its adnexa. I found that fever as a complication occurred, 
among 242 abortions, in 11.57 per cent., two-thirds of this only being due to 
sepsis; in 175 miscarriages fever as a complication took place in 21.71 per cent., 
three-fourths of this being caused by septic infection; and in 218 spontaneous 
premature labors fever occurred in 19.27 per cent., one-half only of this amount 
being due to uterine sepsis. Pyemia is especially common after abortion, in- 
fection taking place usually at the placental site. 

4. Tetanus. This is frequently reported as a sequel to abortion and mis- 
carriage, but is most often an accident in the course of a general septicemia. 

In the 242 abortions, 175 miscar- 
riages, and 218 spontaneous pre- 
mature labors already referred to, 
no case of tetanus occurred. Al- 
though a rare condition, it was 
observed twenty-one times by Ben- 
nington, who collected 41 cases of 
puerperal tetanus. 

5. Perforation of the uterine 
wall. Numerous cases of perfora- 
tion of the uterine wall, during 
curettage after abortions and mis- 
carriages, have occurred. The dan- 
ger of perforation is reduced to 
a minimum if the curette, when 
introduced into the uterus, is 
passed cautiously to the fundus, 
and then, with a firm downward 
stroke, is used to clear the uterine 
walls, especially at the horns. 

The remote dangers of inter- 
rupted pregnancy are: (1) subin- 
volution and displacements; (2) 

septic sequelae; (3) endometritis; (4) polypi; malignant disease; (5) sterility 

(6) anemia; (7) recurrence; (8) neuroses. 

1. Subinvolution and displacements. Involution takes place more quickly 
than after labor at term, unless the abortion is incomplete; its progress being 
delayed by septicemia and retention of the membranes. Subinvolution is 
not uncommon after interrupted pregnancy; and often causes displacements. 
Subinvolution is at times accompanied by a tendency to metrorrhagia, which 
leads to anemia and debility. 

2. Septic sequel®. Local or general sepsis, which sometimes follows abortion, 
may each induce a train of serious sequelae. The former is responsible for 
endometritis, metritis, perimetritis, parametritis and pelvic abscess, salpingitis, 
oophoritis, and sterility. Remote infections may develop as sequelae, as shown 
in the occasional supervention of suppurative arthritis and other pyaemic 
processes at a distance from the pelvis. 

3. Endometritis. As regards endometritis, diametrically opposite opinions 
are maintained. Stumpf, Winter, and Puppe say that it is not the result 




Fig. 496. — Placental Polyp in Situ. Drawn 
from a specimen, u, Utero-placental arter- 
ies; i, internal os; /, lower portion of polyp 
hanging in vagina; b, blood-injected placen- 
tal remnants; e, external os. — (Bumm.) 



ABORTION, IMMATURE AXD PREMATURE LABOR. 399 

of abortion and retention of membranes, and point to Veit's curetted cases, 
in which the endometritis had to be treated after the puerperium was ended. 
They neglect to suggest the possibility of a prior abortion, expectantly treated, 
being at the bottom of the trouble. Reference to the figures given below shows 
a 15.3 greater percentage of subsequent pregnancies when the secun dines 
were instrument ally removed, which is tolerably fair evidence that these 
cases were free from endometritis. 

4. Polypi; Malignant disease. The non-septic residue of the embryo, 
persisting within the uterus, may become nourished and develop into decidual 
and placental polypi, and even into that rare and peculiar formation known 
as deciduoma malignum, although this is seen more commonly after molar 
pregnancy (Fig. 483). 

5. Sterility. Many authorities hold to the opinion that a uterine mucous 
membrane, completely renewed after an abortion, by reason of a curettage, 
is less capable of playing the part of a decidua of pregnancy than one that 
has done so before in whole or in part.* 

Certainly, my figures lead one to a far different conclusion from Puppe's. 
Of 119 cases treated by instrumental curettage, 38, or 31.9 per cent., had expe- 
rienced one or more previous interrupted pregnancies; 5, or 4.2 per cent., 
suffered subsequently in the same way; 48, or 40.3 per cent., gave birth to 
living children at term; and 21, or 17.6 per cent., were found to be pregnant 
from the fourth to the eighth month when visited. These observations were 
made at the patients' homes and the children were seen. Of 28 cases of abortion 
expectantly treated, 10, or 35.7 per cent., had had similar previous experiences. 
None suffered from subsequent interrupted pregnancies; 7 gave birth to living 
children at term afterward (25 per cent.); 5, or 17.8 per cent., were found 
to be pregnant from the fourth to the eighth month when visited. 

6. Anemia. The hemorrhage which accompanies the act of abortion may 
be so profuse, especially if the pregnancy is well advanced, that a condition 
of acute anemia, with all its sequelae, may be established. Hemorrhage due 
to subinvolution has been mentioned (page 397). 

7. Recurrence. The tendency to a recurrence of abortion, and to the estab- 
lishment of habitual abortion, may be set down, with justice, as a sequela of 
interrupted pregnancy, which is highly important by reason of its frequency. 

8. Neuroses. Finally, American authorities enumerate a tendency to 
functional neuroses, and even to psychoses, as one of the sequelae of the inter- 
ruption of gestation. The pathogeny of these affections is obscure. 

Treatment. — 1. Prophylaxis: In habitual premature interruption the cause 
or causes should first be sought. The various conditions which are known 
to favor miscarriage should be considered, one after the other; the uterus 
itself should first be examined; if conception has not taken place, any anomaly 
which is apparent, such as malposition, endometritis, laceration of the cervix, 
etc., should receive suitable treatment. If syphilis exists in either parent, 
a thorough course of antisyphilitic treatment for several months should be in- 
sisted upon, irrespective of previous medication; uterine displacements should 
be corrected, and the uterus may, if necessary, be kept in position by a suitable 
pessary for the first three months, care being taken, however, that the pessary 
causes no irritation ; endometritis or other intrapelvic disease should be suitably 
treated. For the various morbid conditions causing sterility, and their appro- 
priate treatment, the student is referred to works on gynecology. If the woman 

* Puppe: "Untersuchungen uber die Folgezustande nach Abortus." Inaug. Dissert. 

Berlin, 1890. 



400 PATHOLOGICAL PREGNANCY. 

is already pregnant, the uterus is beyond the reach of treatment, save that a 
pessary may be worn for retroversion, during the first three or four months. 
Coitus should be forbidden during pregnancy, and rest in bed for a few days 
before and after the dates corresponding to the usual menstrual epochs is 
advisable; the use at this time of the fluid extract of viburnum prunifolium, 
and the uterine sedatives — hydrastis canadensis, Jamaica dogwood, and Pul- 
satilla — is also advised. Everything that causes mental or physical shock or 
fatigue — excitement or worry ; exercises, walking, standing, prolonged physical 
exertion; improper diet; the use of violent purgatives; railway journeys or auto- 
mobile riding over rough roads — must be avoided. Conditions which predispose 
to abortion, such as severe coughing, vomiting, and intercurrent diseases of 
pregnancy, should receive prompt attention. Another method of dealing with 
habitual abortion is to forbid pregnancy until a given interval has elapsed. 
This is probably the best means for meeting the indication, for the tendency 
to abortion is not inborn but acquired, and physiological rest will enable the 
uterus to outlive this faulty condition. 

2. Threatened interruption: Abortion becomes inevitable when the ovum 
is dead; this condition, however, in the early months can only be inferred. 
The criteria upon which to base an assumption of this event are two: the 
amount of hemorrhage, which when extensive argues for the existence of a 
corresponding degree of separation of the ovum, and the degree of dilatation of 
the os. We should not act upon the supposition that death of the ovum has 
occurred, for the patient should be given the benefit of the doubt, but wait 
until a certain period has expired, during which the hemorrhage may subside 
and the os close. After the sixth month we can tell whether the fetus is dead, 
and in every case an attempt should be made to save the life of the child. The 
patient should be kept in bed in a quiet, darkened room; the rectum and bladder 
attended to; simple liquid diet used, and physical and mental rest secured 
by sedatives. If marked symptoms are present, J of a grain (0.016 gm.) of 
morphin may be given subcutaneously, and the bromides, with viburnum 
prunifolium and hyoscyamus, administered by mouth; the patient remaining 
in bed for several days after all symptoms have disappeared. A useful pre- 
scription in these cases is: Sodium bromide, half an ounce (16 gm.); simple 
elixir, three ounces (96 gm.); tincture of hyoscyamus and extract of viburnum 
prunifolium, of each half an ounce (16 gm.). Take two teaspoonfuls, in a 
sherry glass of water, every three hours. It may be necessary to continue this 
line of treatment several weeks, and it is justifiable when we observe an 
increase in the size of the uterus and other signs that the fetus is alive. The 
management should be the same, whether the chances are in favor of or against 
saving the ovum, and the general principles of treatment are the same as in 
the prophylaxis of abortion. The best sedative is opium, which may also be 
required as an anodyne if pain is present. If the loss of blood is excessive, some 
hemostasis must be effected, but ice-bags and tampons are alike contraindicated, 
since either might have an oxytocic action. Our only resources are postural, 
viz., elevation of the pelvis and, possibly, cold compresses to the vulva. If, 
after several hours, it becomes evident, from the extent of hemorrhage, uterine 
contraction, and dilatation of the os, that abortion is inevitable, the treatment 
for that condition should be instituted. If, on the other hand, the symptoms 
improve, the treatment should be continued until hemorrhage and pain have 
subsided, and in any case for at least forty-eight hours. After this, the patient 
should be regarded as on probation for a week longer, if there is any recurrence 
of pain or metrorrhagia. 



ABORTION, IMMATURE AND PREMATURE LABOR. 401 

3. Inevitable interruptions; early abortions: Authorities are at variance as 
to the indications. Shall the emptying of the uterus be left to nature, or is 
it the physician's duty to evacuate this organ at once? Is it possible that each 
of these plans has its legitimate field? Or, is it possible to combine the two 
plans, by a compromise, without treatment? All methods for the management 
of inevitable abortion may be systematically classified as follows: (1) Purely 
conservative or expectant treatment. Interference is altogether interdicted, 
and sole reliance placed upon the tampon, vaginal irrigation, and ergot. (2) 
Early artificial removal of the decidua or placenta, active treatment so called, 
in which curettage is the routine plan. (3) An intermediate or eclectic method, 
in which intervention is resorted to only in order to control hemorrhage or 
sepsis. The indications for treatment, in all cases of inevitable abortion, are 
the same: namely, first, to control the hemorrhage; and, second, to secure 
complete evacuation of the uterine contents. Both are best fulfilled by instru- 
mental curettage of the uterus, and as a temporary measure, to control hemor- 
rhage while preparations for curettage are in progress, the vaginal tampon 
is most valuable. The latest observations tend to show that in abortions, 
contrary to the generally received opinion, the separation of the decidua vera 
from the uterine wall takes place from above downward, and that consequently 
the complete removal of the decidua by the finger seldom, if ever, takes place. 
Moreover, the removal of small fragments of decidua is easily accomplished 
by the curette, while it is difficult, if not impossible, by the finger. Other 
advantages of the curette are that less dilatation of the cervix is necessary, 
the operation is less painful, and anesthesia is not always required. I advise, 
in all cases of inevitable abortion and in those in which the accident has already 
occurred (incomplete), that the patient be plainly told that a curettage is 
necessary, leaving entirely out of consideration the amount of hemorrhage 
as an indication for interference; and if, upon explaining the danger of retained 
secundines to her, consent for curettage cannot be secured, then only should 
the first method of purely conservative or expectant treatment be followed — 
namely, relying upon the vaginal tampon, irrigation, and ergot. The patient's 
consent having been obtained, curettage is performed in as short a time as 
possible. The vaginal tampon is useful in all cases in which hemorrhage is 
severe and the curettage cannot immediately be performed; it effectually 
controls hemorrhage, aids in the separation of the decidua, and in the dilatation 
of the os. (For curettage, instrumental and digital, and vaginal tamponade, 
see Operations, Part X.) 

I advocate the active treatment of abortion, inevitable or incomplete, 
by reason of the analyses of the records of many hundreds of cases, treated 
by various methods, and especially from an exhaustive study of the pathology, 
bacteriology, duration, complications, sequelae, and treatment of 242 cases; 
166 of which were treated by instrumental curettage; 45 by combined instru- 
mental and digital curettage; 3 by digital curettage only, and 28 by a purely 
expectant treatment. Contrasting the expectant and active plans of treatment 
of abortion, I believe the latter is less dangerous than the abortion and its 
sequelae in cases of retention, and curettage makes sure that everything is 
removed; involution and time are necessary for convalescence after abortion; 
the one is hastened, the other cut short, after curetting; this is, of course, a 
boon to the working classes ; the expectant plan requires two weeks for itself 
alone; after instrumentation the patient may leave her bed on the fifth day; 
pain and physical discomfort, as well as mental perturbation, are less than 
in the expectant method; moreover, a large proportion of so-called complete 
26 



402 



PATHOLOGICAL PREGNANCY. 



abortion cases are followed by hemorrhages, subinvolution, acute and chronic 
sepsis; hemorrhage is always greater with expectant treatment; not more 
than half an ounce is lost by instrumentation, before the fourth month. In 
the first two months and a half, emptying of the uterus can be accomplished 
with curettage alone, the canal admitting the finger with difficulty and pain 
if anesthesia is not used. Uterine atony is controlled by irrigation and uterine 
tamponade with gauze; ergot is rarely called for, the placental forceps only 
occasionally. If curettage for any reason cannot be accomplished at once, 





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Fig. 497. — Miscarriage at Five and a Half 
Months; Manual Extraction of the Pla- 
centa; Septic Intoxication; Curettage on 
the Fourth Day. 



Fig. 498. — Incomplete Early 
Abortion. Septic Intoxica- 
tion; Curettage. 



the vagina may be tamponed with sterile gauze until the operation can 
be carried out. This course may also be pursued when curettage is refused, 
and the gauze packing may be left in for twenty-four hours. Again, if the 
accoucheur is a beginner, who dreads assuming the responsibility of forced 
dilatation and curettage, he is justified in adopting the conservative plan, 
and in temporizing with a gauze pack until dilatation occurs. Inevitable 
abortion may terminate, in a small number of cases, in expulsion of the ovum 
almost entire in which case it is arrested in the cervical canal. Under these 



ABORTION, IMMATURE AND PREMATURE LABOR. 403 

circumstances curettage may not be necessary, as hemorrhage may cease after 
simple extraction with the finger or forceps. In case the ovum is too large 
to pass through the os, the latter may be dilated. 

Late abortions. In the management of late abortions the treatment which 
has been advised for early abortions is preferable during the early portion 
of the second third of gestation; since clinically we are unable to draw the 
line so sharply between early and late abortion as some authorities would 
have us do. With the advance of pregnancy the treatment should become 
less and less aggressive, until it gradually merges into that of premature labor 
and labor at term. The real criterion of late abortions is the marked pro- 
longation of the third stage of labor, which is due to the facts that placental 
development has occurred, and that the placenta is frequently adherent to 
the uterus. In the removal of an adherent placenta the manual method, as 
stated, is usually preferable, while for the removal of the decidua the curette 
is to be preferred. It is best not to use the curette to remove the placenta 
after the twelfth week. It is not consistent or safe to do so, and as a greater 
number of abortions occur at the third month, the method of treatment must 
be a combined one. The separation of the placenta is readily accomplished 
by digital curettage; the curette removes the decidua vera. Bimanual com- 
pression of the fundus uteri by two fingers internally and the other hand exter- 
nally upon the abdomen, as a method of placental expression, is quite painful, 
frequently ineffectual, and is not to be recommended. 

4. Incomplete and septic abortions: If the fetus has been expelled from the 
uterus, the membranes and placenta remaining behind, the indication is to 
curette at once, even if forcible dilatation is required. In suspected and estab- 
lished sepsis the greatest care must be used in all examinations and operative 
procedures not to open up new areas for infection. Sepsis may not be recog- 
nized as such, but we may assume that it is present if a high pulse exists, with 
or without fever. In this class of cases, as in infection after labor at term, I 
use the gentlest means to clear the uterus of retained material. Usually the 
finger and irrigation are sufficient. In exceptional cases I still resort to the 
dull curette where the size of the uterine cavity or the nature of the retained 
matter do not allow of the efficient use of digital curettage. The uterus is then 
irrigated with several quarts of a saline or antiseptic solution, and further intra- 
uterine treatment is contraindicated, with the possible exception of an occasional 
irrigation, most carefully administered. The remaining treatment of septic 
abortion does not differ from that of puerperal sepsis in general. 

Premature labor. This is the same as the management of labor at full term. 
(See page 514.) 

After-treatment. — The after-treatment of abortions, miscarriages, and pre- 
mature labors should approach as nearly as possible to that of the puerperium 
at term. (See Part VI.) Unfortunately, after early interruptions of pregnan- 
cies patients insist upon making light of the condition, leave the recumbent 
position too early, and generally abandon treatment so essential for the attaining 
of proper involution. Involution is relatively slower after abortions and mis- 
carriages than during the normal puerperium; hence the dangers of subinvo- 
lution, uterine displacements, and pelvic inflammations should always be 
explained to the patient, and the importance of the same attention to the 
condition as after labor at term. The combined and persistent use of ergot 
and strychnin I have found of the greatest value in hastening involution 
and in preserving the tone of the uterine ligaments. I use one or two 
grains (0.06 to 0.12 gm.) of ergotin, and one-thirtieth (0.002) of a grain of 
the sulphate of strychnin, three times a day, in capsules or tablets. As 



404 



PATHOLOGICAL PREGNANCY. 



lactation is absent, this function does not constitute an objection to the use 
of these drugs. Vaginal and uterine irrigation is unnecessary, except after 
incomplete or neglected abortion, or miscarriage with symptoms of uterine 
sepsis. Late in the puerperium very hot vaginal irrigations are of benefit 
in assisting involution. Ergot and its derivatives must not be given until 
the uterus is free from the products of conception. It is just as necessary 
for a physician to know how to treat abortion as it is to treat normal labor, 
and the matter should receive adequate attention in the schools. 



XX. ECTOPIC GESTATION. 

Definition. — Extrauterine pregnancy, also known as ectopic gestation, or 
extrauterine fetation, consists in the development of the fertilized ovum in 
any part of the generative tract outside of the cavity of the uterus. 

Historical. — The Arabian physician Albucasis probably reported the first case, in the 
eleventh century. It is supposed that Jacob Nufer, in 1500, operated on his wife for extra- 
uterine pregnancy. Dirlewang and Cantax, 1547, reported the case of a woman who was 
delivered several times by operation. Riolanus, 1604, and Mauriceau, 1669, were the first 
to depict extrauterine pregnancy; Dionis, 1689, also reported a case. Biancte, 1741, made 
a classification of the various forms; as did Josephi at a later date; Dezmeiris, 1836, made 
a classification which is used to this day. In the last few years much study has been given 
to this subject; Lawson Tait has had a remarkably wide operative experience in these 
cases, and has written extensively on the subject, so also has Bland Sutton, who formulates 
the rule, also indorsed by Tait, that "all forms of extrauterine gestation pass their primary 
stage in the Fallopian tube." This opinion is held by many at this day, in contradistinction 
to the classification so long in vogue and still supported by many authors, which will be 
stated later. 

Frequency and Classification. — The occurrence of this condition is rare, the 
proportion to normal pregnancy being variously estimated as from one in five 
hundred to one in ten thousand. Many cases are detected, while others are re- 
garded and treated as instances of pelvic hematocele. The number reported 
has been greatly increased with the progress of gynecology. It is also greater 
in large cities; probably the abundant gynecological material, the possibility 
of immediate operation to substantiate the diagnosis, and perhaps the greater 
prevalence, in cities, of gonorrhea with all its baneful results, may account 
for this increase. 



1. Ovarian Pregnancy. 

(The fecundated ovum 
remains in the Graafian 
follicle and is there de- 
veloped, 4.8 %.) 



2. Abdominal or Perito- 
neal Pregnancy. (The 
fertilized ovum locates 
itself in the abdominal 
cavity, 8.5 %.) 



3. Tubal Pregnancy. (The 
fertilized ovum is wedged 
in the tube, 86.7 %.) 



Internal ovarian preg- 
nancy. 

External ovarian preg- 
nancy. 



Primary abdominal preg- 
nancy. 

Secondary abdominal preg- 
nancy. 



Tubo-abdominal 
nancy. 



preg- 



Tubal pregnancy proper. 

Interstitial tubal preg- 
nancy. 



The ovum remains imprisoned 
in the Graafian follicle. 

The ovum begins to migrate 
toward the rupture in the 
follicle and is developed 
partly in the follicle and 
partly in the peritoneum. 

The ovum falls into Douglas's 
cul-de-sac, and stays fixed 
there from the beginning. 

The ovum develops first in the 
tube or ovary, and finally 
falls into the peritoneal 
cavity, where it continues 
its growth. 

The ovum develops partly in 
the tube, and partly in the 
abdominal cavity. 

The ovum is fixed about th 
middle of the tube. 

The ovum is developed in that 
part of the tube which is 
connected with the uterine 
wall. 



ECTOPIC GESTATION. 



405 




Fig. 499. — Ovarian Pregnancy. t, Tube; o, ova- 
rian ligament; g, gestation sac. — {Martin*) 



The varieties of extrauterine pregnancy may also be divided into primary 
and secondary forms. Under the primary forms are: (1) Ovarian (Fig. 499.) 
This consists of two varieties, and originates as follows: the internal form 
arises from the fertilization of an ovum in the substance of the ovary, the sper- 
matozoon entering the rent in the follicle, which then closes, retaining the 
fertilized ovum in its original resting-place; or the spermatozoon may enter 
the unruptured follicle. These 

two methods are entirely mat- L 0> 

ters of conjecture. In the 
external form the rent in the 
follicle is supposed to remain 
open. (2) Abdominal (doubt- 
ful). Here the ovum, in its 
passage to the tube, is de- 
layed in the abdominal cav- 
ity. (3) Tubo-ovarian. In 
this, through adhesion be- 
tween the tube and ovary, 
the ovum develops midway 
between the two. (4) Tubal 
{Fig. 500): (a) Ampullar, 
(b) isthmial, (c) interstitial. 
These three varieties are clas- 
sified according to the posi- 
tion of the ovum in the tube. The secondary form arises by rupture of a 
tubal pregnancy, in the portion covered by peritoneum, thus throwing the 
whole product of conception, or the fetus alone, into the abdominal cavity. 
The result would be a secondary abdominal pregnancy, ventral if free in the 
abdominal cavity. If, however, it remains between the folds of the broad 
ligament and continues to develop, it forms a broad-ligament pregnancy. 

This variety, in its growth, 
will press apart the folds of 
the broad ligament, and be- 
come intra-ligamentous, or 
subperitoneo-pelvic. Con- 

tinuing, the intra-ligamen- 
tous pregnancy may lift up 
the abdominal peritoneum, 
and become a purely extra- 
peritoneal form. 

One condition not yet 
mentioned is the very rare 
one in which the ovum de 
velops in the supplementary 
horn of a bilobed uterus. This is not, strictly speaking, an extrauterine preg- 
nancy, but really a pregnancy in an abnormally formed uterus. It is men- 
tioned here because clinically it leads to the same results (see page 414). 
Instances have been noted of both an intrauterine and an extrauterine preg- 
nancy existing at the same time; the occurrence of an extrauterine pregnancy 
in one tube has been shortly followed by the same condition in the other 

* Ueber ektop. Schwangerschaft, Fig. 1. 

t "De gravitate extrauterina " : In. Diss., Greifswald, 1855. 




Fig. 500. — Tubal Pregnancy. — {Sommer.\) 



406 



PATHOLOGICAL PREGNANCY. 



tube. A plural (twin) pregnancy in a Fallopian tube has been observed , 
though very rarely, and also a simultaneous tubal pregnancy on both sides. 

Relative Frequency. — The various forms differ in frequency of occurrence. 
The tubal is the most frequent, then follow interstitial and ovarian, the last 
of which is the most rare. The other forms are due to rupture. 

Etiology. — The etiology in individual cases is always obscure. The age 
at which it generally occurs is between twenty and thirty years. In general 
terms any condition which prevents the passage of the ovum to the uterus,, 
but which does not prevent the passage of the spermatozoa to the ovum, may 
cause this condition. There are two main classes to be considered: (i) Patho- 
logical conditions of the tube; (2) malformations of the tube. Under the 
first class are grouped all the inflammatory conditions which will result in 
hyperplasia or neoplasmic growth, these conditions leading to the occlusion,, 
more or less, of the lumen of the tube. This condition may follow some form 
of salpingitis, either catarrhal or gonorrheal, which causes both an exfoliation 

of epithelium and an infiltration 
of the tubal tissues. In such a 
case the normal peristalsis of the 
tube will be affected; inspissated 
mucus may block the lumen ; pres- 
sure on the tube by an abdominal 
growth of some kind, or peritoneal 
inflammatory bands, may distort 
the structure. It is well known 
that extrauterine pregnancy occur 
most frequently in multiparas, and 
seldom in women under thirty 
years of age. A large proportion 
of cases occur in women who have 
either been sterile, or in whom a 
long period has passed since the 
last pregnancy. Recurrent cases 
are very rare, but when occurring, 
they may succeed each other, or 
be separated by a normal uterine 
pregnancy. 
Pathology of the Various Forms.— Tubal— This, as has been stated, is 
the most common form. The ovum develops at some point in the tube; 
generally it is situated at about the junction of the middle and outer thirds. 
As soon as it begins to grow, it meets -with resistance from the sides of the 
tube; this structure, in expanding to meet the needs of the growing embryo,, 
becomes hypertrophied and assumes a spindle shape; the walls of the tube 
do not hypertrophy to the same degree in all their parts, but here and there 
occurs a thinning, and it is at one of these places, generally at the upper 
or posterior portion of the tube, that rupture occurs. Usually there is 
not a true placenta, probably because laceration and death take place 
before the time at which the placenta is normally formed; the ovum is sur- 
rounded by amnion and chorion, the latter containing the villi, which 
embed themselves in the mucous lining of the tube, and serve to fix the ovum 
in its position. The decidua is replaced by hyperplasia of the tubal tissues, 

* "Beitrage zur Kasuistik, Prognose und Therapie der Extrauterinschwangerschaft,''" 
Prag, 1891, Taf. r. 




,1 



Fig. 501. — Intraligamentous Development op 
a Tubal Pregnancy, g, Gravid tube; e, ex- 
ternal os; u, uterus. — (Schauta.*) 



ECTOPIC GESTATION. 



407 




■Interstitial Pregnancy. 
— {Rosenthal.*) 



including the mucosa, fibrous and muscular coats, forming a sort of pseudo- 
decidua, the uterine extremity of which has been found open and in direct 
communication with the uterine mucosa. The tubal mucous coat is not fur- 
nished with glands, so that a true decidua cannot be said to exist, there being 
no enveloping membrane of the 
ovum, analogous to the decidua 
reflexa. On account of the loose 
attachment of the ovum in its 
abnormal situation, hemorrhage 
from the laceration of the chor- 
ionic villi is very apt to take 
place. Extravasation of blood 
then occurs between the villi and 
often is the cause of rupture. In 
case rupture does not occur, the 
ovum may be changed into a 
fleshy mole, analogous to the 
uterine mole, this being most prob- 
ably the origin of many cases of 
"hematosalpinx," so called. On 
microscopic examination the tube 

contents show chorionic villi, thus proving the existence of pregnancy. The 
ovum may grow (i) upward. This generally results in early rupture; if this 
event does not occur, the growth is continued until a pedunculated tumor is 
formed, and this can be demonstrated by abdominal palpation to be attached 

to the uterus, which is 
pushed to one side or re- 
troverted; thus is produced 
the intraperitoneal form. 
(2) Vicariously its growth 
is downward, separating 
the folds of the broad liga- 
ment ; this is the intraliga- 
mentous form (Fig. 501). 
Although ruptures may 
occur in this form, preg- 
nancy may continue unin- 
terrupted till term, for the 
broad ligament affords con- 
siderable support. In this 
case the growth is not 
upward, but fills the pelvic 
cavity. Rarely, after the 
growth has reached the 
pelvic floor, it may grow 
backward and upward, rais- 
ing the posterior deflection 
of the peritoneum, behind 
which it develops; this is called the extraperitoneal variety. Tubal abortion: 
In early pregnancy, previous to the second month, before the free end of the tube 
* "Centralbl. f. Gynakol.," 1896, No. 51, S. 1297. 
t " Beschreibung einer graviditas interstitialis uteri," Bonne, 1825. 




Fig. 503 .—Interstitial Pregnancy. Pregnancy de- 
veloped in the wall of the left horn ; the sac ruptured 
and the chorionic villi show on the surface of the 
uterus. rl, Right round ligament; a, adhesions; e, 
external os; r, rupture; //, left round ligament. — 
(Mayer. •[) 



408 PATHOLOGICAL PREGNANCY. 

is closed, the mole may escape into the peritoneal cavity, accompanied by 
numerous blood-clots. In case the ovum is not entirely extruded, there may 
ensue repeated hemorrhage, explaining many cases of hematocele which used to 
be otherwise accounted for; according to Sutton, the abdominal end of the tube 
is usually closed by the end of the eighth week by means of a ring of peri- 
toneum; in these cases the pregnant tube ruptures almost without exception; the 
rupture may be into the broad ligament. Later, the walls of the broad liga- 
ment may give way and a secondary rupture occur into the peritoneal cavity. 
Many complications are incident to these conditions; viz., intestinal strangula- 
tion, perforation of the bowel, rupture and displacement of the bladder, and 
adhesions. 

Interstitial or Intramural Pregnancy. — In this variety there is little room 
for growth, as the ovum is lodged in that part of the tube which passes through 
the uterine wall. The projection, in the first increase of the ovum, consists 
of an hypertrophy of the uterine muscle, with the broad ligament and Fallopian 
tube covering it. Soon, however, the uterine muscle fails to contain the ovum, 
and rupture follows. If the growth has been toward the abdominal cavity, 
the rupture takes place into the peritoneal cavity and ends the pregnancy. 
At times, however, the growth is toward the uterine cavity, and after rupure 
the fetus is expelled into the uterus itself and escapes by the normal channel; 
the symptoms then are those of an ordinary abortion, and the patient is apt 
to recover with no serious results (Figs. 502 and 503). 

In the tubo-ovarian variety the normal fetal membranes are developed, but 
the outer covering of the sac consists partly of tube and partly of ovary. This 
form is usually terminated by early rupture, from the lack of sufficient tissue 
to support this increasing mass. 

Ovarian. — Spiegelberg declares that in order to prove ovarian pregnancy, 
the following conditions are to be demonstrated: (1) The tumor must corre- 
spond to the situation of the ovary; (2) it must be connected to the uterus 
by the ovarian ligament; (3) the tube must be proved intact; (4) ovarian 
tissue must be found in the mass of the sac. There are recorded a number 
of cases which have complied with these conditions. In internal ovarian preg- 
nancy the ovum develops, and although termination by rupture is probable, 
it may reach full maturity. If rupture occurs before the third month, it may 
be complicated by severe hemorrhage, or death of the embryo, followed by 
its abortion, while the gestation sac is converted into a cystic tumor. After 
the third month the cyst may contain the fetal parts. The fetal membranes 
are well developed in this variety. 

Abdominal. — The primary form occurs when the ovum becomes fertilized 
in the peritoneal cavity, perhaps while still in contact with the ovary (external 
ovarian pregnancy). As it has no suitable place for attachment, it falls to 
the abdominal floor, and becomes attached in one or other of the iliac fossae, 
in Douglas's pouch, or to the intestines. The fetal membranes, in this 
form also, are well developed; the peritoneum under the ovum becomes 
very much congested and hyperplastic, and an exudate is thrown out, which 
surrounds the ovum and forms a sort of cyst wall, with new-formed blood- 
vessels. This structure serves the purpose of the decidua; while within the 
uterus a true decidua is formed, and pregnancy may continue to term. The 
secondary form (metacyesis) is far more common, and exists when the ovum 
escapes into the abdomen, after the rupture of an extrauterine or even intra- 
uterine pregnancy. The embryo continues its growth in whatever part of 
the abdomen it has lodged; the fetal membranes are developed about the 



ECTOPIC GESTATION. 409 

ovum, while the placenta may or may not be retained in the original site of 
the ovum. If the former condition is true, the connection between the devel- 
oping embryo and placenta is maintained by the umbilical cord. In rupture 
of the intrauterine pregnancy the rent probably occurs at the point of some 
previous weakness of the uterine wall, as after a Cesarean section. In this 
case, too, the fetus is apt to perish at once, but rarely the pregnancy may con- 
tinue to term; fetal death, however, commonly occurs during labor. This 
is probably due to the separation of the placenta, as a result of labor, pains. 

Changes in the Tube and Uterus. — Decidua and placenta are formed ; in rare 
cases a decidua is formed in the opposite tube. In the uterus the changes 
are the same as in normal pregnancy; up to three months hypertrophy and 
endometrial changes occur, after which the process remains at a standstill; 
a decidua vera forms. 

Clinical History and Terminations. — Those patients in whom this affection 
does not terminate fatally frequently live a life of invalidism, consequent upon 
the shock and hemorrhage which occurred with the rupture of the fetal sac. 
There may follow ulceration, with abscess formation, when the fetus is retained; 
the abdominal walls, bladder, and intestines may be perforated by the extrusion 
of the fetal parts ; there may occur obstruction of the intestine by inflammatory 
bands which were formed during pregnancy. Ectopic gestation rarely pro- 
ceeds without accidents, like a normal uterine pregnancy; its continuance 
to term is exceptional; rarely does the fetus develop in the normal manner; 
it terminates most often by rupture of the fetal cyst; there may be symptoms 
of false labor, or retention of the dead fetus. Duration: The duration varies 
according to the variety, depending, in great part, on the degree of distensi- 
bility of the walls of the fetal cyst. Rupture of the fetal cyst: This occurs when 
its further growth is prevented by the surrounding parts. It takes place about 
the third month in interstitial pregnancy, the variety in which the uterus is 
largest. It may occur at any period of pregnancy, but especially between 
the eighth and twelfth weeks in pure tubal pregnancies, which come so rarely 
to term that certain authors deny this termination. Those cases reported 
by Saxthorp and Spiegelberg, in which the pregnancy is supposed to have 
continued to term, are probably instances of the subperitoneal, pelvic, or 
secondary abdominal varieties. It occurs late in tubo-abdominal pregnancy, 
and is less frequent than in the other tubal varieties. It is less frequent and 
less early in ovarian pregnancy than in tubal; it is rare in abdominal preg- 
nancy. Signs and prognosis of rupture: Rupture is sudden, spontaneous, or 
provoked by some insignificant traumatism. Sudden, very sharp pain radiates 
over the abdomen, which becomes sensitive to the slightest touch; the face 
is pale, the pulse small, frequent, and thready; there exists "air-hunger," with 
audible yawning ; the extremities are cold ; there is syncope or tendency thereto ; 
the mental faculties are clear. These signs are due to hemorrhage. Soon 
ensue the peritoneal signs: hiccough, nausea, vomiting, extreme sensitiveness 
of the abdominal parietes. The gravity of the rupture varies according to 
the extent of the hemorrhage and the intensity of the peritoneal phenomena. 
The woman may succumb immediately, or at the end of some time; in con- 
sequence of the anemia due to the successive hemorrhages, or from peritonitis. 
Death is almost certain when rupture occurs in a cyst containing a dead and 
putrefied fetus, the patient being carried off by an acute peritonitis. At the 
end of pregnancy a cyst may rupture without causing either hemorrhage or 
peritonitis; a tolerance of the intestines to the presence of a fetus free in the 
abdominal cavity existing. Point of rupture of a fetal cyst: A fetal cyst may 



410 PATHOLOGICAL PREGNANCY. 

rupture (i) at the level of the anterior abdominal wall, the most frequent points 
being at the level of the umbilicus and in the peri-umbilical region, which is 
often 'favorable to the patient; (2) into the intestine (one-fourth the cases), 
and more often into the large intestine, especially into the rectum. This ter- 
mination is ushered in by abdominal pain and frequent calls to evacuate the 
bowels; this may last for months and years, and is sometimes complicated 
by septicemia; (3) into the vagina (one- twentieth of the cases); (4) into the 
bladder (one-twentieth of the cases); (5) into the uterus, which is exceptional; 
(6) by various channels; a cyst may rupture at the same time into the vagina 
and intestines; into the rectum and vagina; into the rectum and the bladder. 
False labor and time of its appearance : False labor occurs generally at term 
in ectopic pregnancy, rarely after term. It may occur prematurely, at the 
end of the seventh or eighth month. The symptoms are intermittent pains, 
analogous to those of true labor, due to uterine contractions, the fetal tumor 
not contracting; a sanguinolent oozing, or sometimes a true hemorrhage, 
accompanies these pains ; the cervix relaxes and is large enough for the entrance 
of two fingers, but is not obliterated. False labor ends with the expulsion 
of a decidua. The fetus generally succumbs at the end of some hours and 
is retained. False labor lasts from eight hours to a week, then gradually 
subsides, unless there has been a rupture; labor does not generally return. 
Retention of the dead fetus: Death of the fetus can occur in the first months 
of pregnancy, or succeed false labor. Pregnancy then enters the period of 
retrogression; the abdomen diminishes, the sympathetic phenomena of preg- 
nancy disappear, and by way of compensation milk appears. Different trans- 
formations of the dead fetus: If the fetus dies in the first months it is dissolved, 
and entirely absorbed, as is the amniotic fluid, the fetal cyst diminishing 
or even completely disappearing. At a later period of pregnancy the fetus 
cannot be absorbed. It may undergo fatty degeneration into adipocere, mum- 
mification, or calcification, becoming a lithopedion. 

Symptoms. — There are certain symptoms common to all varieties, and 
others characteristic of the individual varieties. In all instances of extra- 
uterine gestation there are found the identical reflex symptoms which accom- 
pany normal pregnancy. These generally follow a long period of sterility 
in which symptoms of endometritis have manifested themselves. The symp- 
toms common to all forms are suppression of the menses; increase in size 
of the abdomen and of the breasts; digestive and sympathetic disturbances; 
reflex nausea and vomiting, commonly severe and beginning at an early period. 

Two signs are peculiar to extrauterine pregnancy: viz., (a) peritonitic phe- 
nomena; (b) bloody discharge. The peritonitic symptoms begin at the end 
of the first month and may continue during all of pregnancy; they are pains, 
more or less sharp, situated in the lower abdomen, radiating to the loins, and 
returning as a rule at every menstrual period; they resemble labor pains, are 
rarely continuous, and are accompanied by swelling of the abdomen, which 
is sensitive to the least pressure, the patient being often obliged to stay in bed 
during these attacks. The discharge of blood occurs in two-thirds of the cases; 
it is very painful, and is often accompanied by expulsion of the decidua, as 
a whole or in pieces, while the extrauterine pregnancy continues to develop. 

In primary abdominal pregnancy there may be no disturbance at all of 
the menstrual function. As a rule, the re-establishment of menstruation 
indicates the death of the fetus, and points to an early rupture of the sac. The 
mammary changes are identical with those in normal pregnancy; vaginal 
pulsation can usually be felt; rectal tenesmus sometimes causes extreme dis- 



ECTOPIC GESTATION. . 411 

comfort. According to Coe, pain alone, when not accompanied by a clear 
history of menstrual irregularity, symptoms of pregnancy and the presence 
of a tumor at the side of the uterus, or in Douglas's pouch, known to be of 
recent development, is pathognomonic of extrauterine pregnancy only under 
certain conditions: viz., that the pain be of a sharp, colicky character, dis- 
tinctly localized on one side, attended with faintness more or less marked, 
and usually followed by intervals of hours or days of complete remission. The 
pulse is accelerated, but there is no rise of temperature as in inflammatory 
conditions. By many obstetricians pain is considered one of the most striking 
symptoms of this condition. The temperature may also be above normal, 
even as early in the course as the fourth week; the elevation, however, is gen- 
erally slight. The general health may suffer. The bloody discharge occasion- 
ally necessitates tamponing; it is sometimes red, sometimes the color of coffee, 
again sero-purulent ; it comes from the rupture of the vessels of the decidua 
and can with difficulty be differentiated from hemorrhage, often simultaneous, 
which comes from the separation of a tubal placenta. If tubal gestation could 
be diagnosticated before the occurrence of rupture, in many cases the fatal 
termination now so common might be avoided; the prognosis would be better. 
Sometimes death overtakes the patient before there is the slightest suspicion 
of her condition. However, if a case present all the evidences of early preg- 
nancy, in which there are irregular, bloody discharges, perhaps containing 
membranous shreds, and, in addition, if there is abdominal pain, there is some 
hope that on careful examination the true condition of affairs may be ascer- 
tained. A symptom in tubal pregnancy which has been much emphasized 
for its value is that after the cessation of menstruation for one or two periods 
there supervenes an irregular, bloody discharge. The use of the uterine sound 
is not legitimate unless the existence of intrauterine pregnancy be absolutely 
disproved. The most characteristic symptom, although it is not so frequently 
found in this form as in tubal pregnancy, is the existence of metrorrhagia 
together with the signs of early pregnancy. Frequent and severe attacks of 
abdominal pain are present almost without exception. This symptom, if 
combined with hemorrhage and a discharge through the vagina of decidual 
tissue, should at once arouse suspicion. Two signs are very valuable — one 
is the softened condition of the os and cervix, while they are often pushed 
out of place by the growing cyst, or bound down by perimetric adhesions 
Unfortunately, in the early weeks, when the signs are still uncertain, it is most 
important that the diagnosis be made in order to avoid death of the patient 
from rupture. This condition must always be regarded as a malignant growth. 
Without treatment a large percentage of the patients die. Whenever there is 
any doubt as to the diagnosis of ectopic gestation, either before or after rupture 
has occurred, it is strongly recommended to open the posterior vaginal cul-de- 
sac and make, if necessary, a digital examination of the suspected tumor. (See 
Part X.) This operation as a diagnostic resource is now regarded as perfectly 
safe, and has the further merit of paving the way for early conservative treat- 
ment when indicated. 

Physical Signs. — The existence of two neighboring tumors, one situated to 
the right or to the left of the median line and slightly movable ; the other placed 
at the side of the former, more regular, and giving contractions (hypertrophied 
uterus). The cervix is soft and elevated, so that it is sometimes necessary 
to introduce the hand in order to feel it; the uterus is usually in front of the 
fetal tumor; rarely it is behind in relation with the anterior face of the sacrum; 
there is a furrow between the cervix and the tumor; sometimes the uterus 
forms one body with it. 



412 • PATHOLOGICAL PREGNANCY. 

The fetal cyst is regular and low in situation, according to the variety of ecto- 
pic gestation and the point of placental insertion. It often has so thin a wall 
that the fetal sutures or small parts can be felt; again, it may be so thick that 
the fetal parts cannot be felt at all, even though strong pressure be made; in 
the last case either the whole or part of the placenta is in the small pelvis. From 
the fourth month the uterine tumor remains stationary ; only the fetal cyst con- 
tinues to enlarge and forms an irregular tumor, deviating to one side, with the 
long axis transverse. Pain becomes more and more sharp; successive attacks of 
partial peritonitis occur; active movements of the fetus and fetal heart-sounds 
can be perceived from the fifth month, and give positive proof of the existence 
of extrauterine pregnancy, which has already been suspected. 

Differential Diagnosis. — This is always difficult, especially in the first period, 
when it can never be made with certainty, and when the diagnosis of proba- 
bility is sufficient ground for surgical interference. In the first period of uncer- 
tainty the condition can be confounded with ovarian cysts, fibromata, different 
varieties of salpingitis (especially hematosalpinx), hematocele both retro-uterine 
and peritoneal. The history, the functional disturbances of pregnancy, the 
deviation of the uterus, and the simultaneous appearance of a neighboring 
tumor point to the probability of the existence of extrauterine pregnancy. 
A pregnant double uterus, with retroversion of the gravid uterus, is very difficult 
to differentiate. In retroversion with ectopic gestation there exist only two 
tumors. The reduction of the retroversion is possible, which is not possible 
in ectopic pregnancy. Displacements of the uterus give rise to difficult com- 
plications. In retroflexion, when trying Hegar's sign, the cervix may be taken 
for the uterus and the body for a tubal pregnancy. Pregnancy in a bi-lobed 
uterus presents a history almost identical with that of tubal gestation. A 
good way to make the differential diagnosis is to observe the relations between 
the tumor and the round ligament. If the pregnancy is in the uterine cornu, 
this ligament will be pushed outward and be external to the sac, while if it 
is tubal, the ligament will be connected with the uterus on the inner or uterine 
side of the cyst. Hemorrhage and expulsion of the placenta would point to 
abortion. The existence of a double tumor, persisting after all these phenomena, 
corrects the mistaken diagnosis. 

In the second period of uncertainty the diagnosis is easier, since pregnancy 
is already sure. The fetus is more superficial in extrauterine pregnancy than 
in normal pregnancy; a double tumor exists in ectopic gestation. During 
the retention of the dead fetus the diagnosis is very difficult. In the first period 
the retention of the dead fetus could be confounded with many tumors, but 
the history might suggest an ectopic pregnancy. In the second period the 
certain signs of pregnancy, and the presence of a large and soft tumor, furnish 
valuable data ; osseous crepitation can sometimes be felt by bimanual examina- 
tion; the diagnosis is then confirmed; if the cyst is opened, the parts extruded 
prove the diagnosis. The diagnosis of the variety of the ectopic gestation 
is very difficult, if not impossible. Even at autopsy it is not always possible 
to prove it with certainty. 

Prognosis. — For the child it is nearly always fatal. There are noted cases 
of 6 1 children who were living when extracted. They may continue to 
live if sufficiently developed at birth. Often they are deformed, club-foot 
being particularly common, due to insufficiency of the amniotic liquid and 
resistance of the walls of the fetal cyst. For the mother it is very grave. The 
mortality is about 50 per cent. The prognosis is so grave that surgical inter- 
ference should always be instituted. 



ECTOPIC GESTATION. 413 

Treatment. — Modern treatment is summed up in the statement that every ex- 
trauterine pregnancy that is diagnosticated demands surgical intervention. The 
first operation after a definite diagnosis was performed by Veit in Berlin in 1885. 

Time for Intervention. — Intervention should be immediate, in the first 
period of ectopic pregnancy; but in the case of retention of the dead fetus 
it should be retarded as long as possible, on the ground of conservative obstet- 
rical surgery. When the ectopic pregnancy has passed five months, and the 
fetus is still alive, the woman should be kept absolutely quiet, if the operation 
is delayed, in order to increase the chances of saving the fetus. 

Choice of Operative Method. — This lies between laparotomy, extraction of 
the fetal cyst, or of the fetus, by the abdominal method; and elytrotomy or 
colpotomy, extraction of the fetal cyst by the vaginal route. Whenever the 
fetus is alive, laparotomy should be employed. The median abdominal in- 
cision is the first step. Then an attempt is made to perform a total extraction 
of the cyst, if the adhesions to neighboring organs are not too close. If there 
have been symptoms of peritonitis, and if the adhesions are very firm, it is 
preferable not to remove the cyst, but to suture it over the circumference of 
the abdominal incision, before opening it and extracting the fetus. The ex- 
traction of the placenta makes the patient liable to severe hemorrhage. Many 
leave it in place, carefully draining the cyst cavity, in order to permit the escape 
of fluid. The placenta is removed by fragments, at the end of fifteen to twenty 
days, when there exists a granulating membrane at the internal surface of the 
cyst. // the fetus has died, intervention should be the rule, for putrefaction 
is to be feared at any moment. Elytrotomy would be the preferable method 
if the cyst is very accessible by the vagina; it consists in incising the vagina 
distended by the fetal cyst, and in bringing the fetus across the gaping incision, 
which can be enlarged in every direction; the placenta should be extracted, 
if it is possible to separate it, and the cavity of the cyst should be packed with 
gauze and drained. Laparotomy, on the other hand, should be preferred, 
if the fetal cyst is especially developed in the abdomen. If possible, the fetus 
should be extracted by dilating the opening of the fistulous passages. The 
extraction of the osseous parts may prove difficult and necessitates the use of 
the cephalotribe. The indication, however, will vary with many conditions, 
such as the period and variety of pregnancy, whether there has been rupture, and 
whether the fetus is living or dead. If in the early stages, laparotomy should 
be performed and the fetal sac should be removed. After rupture immediate 
laparotomy is indicated, the blood should be cleaned out of the peritoneal 
cavity, the sac should be ligated and entirely removed. As a rule, death does 
not occur till some hours after rupture. In the interstitial form laparotomy 
may be performed after rupture and hemorrhage have taken place. The 
bleeding points should be ligated and the sac cleared of its contents. If this 
is not possible, the uterine and ovarian arteries should be ligated, or even the 
uterus may be removed supra- vaginally. In late extrauterine pregnancy the 
fetus and its sac should be extracted by abdominal section. If the fetus is 
already dead, laparotomy should be performed and the fetus and its sac re- 
moved. If the excision of the sac is too difficult or dangerous, some weeks 
after death the cord may be cut short and the remains of the placenta be left 
behind, and after stitching the sac wall to the abdominal wall the sac may 
be drained externally. In the case of extraperitoneal rupture, the conditions 
are not so urgent, and if the patient rally well it is better not to interfere at 
all till later. According to Kelly, the best method of attacking this class 
of cases, when ready for operation, is by the vaginal route. 



414 



PATHOLOGICAL PREGNANCY. 



XXI. PREGNANCY IN ONE HORN OF A UTERUS BICORNIS 
OR UNICORNIS; CORNUAL PREGNANCY. 

Cornual pregnancy is the development of an ovum in one horn of a two- 
horned uterus or in one side of a double uterus (Figs. 504 and 505). Fortun- 
ately the condition is rare, for women with malformations of the uterus are 




Fig. 504. — Pregnancy in the Rudimentary Horn of a Uterus Unicornis. The rudi- 
mentary horn is shut off from the uterine cavity. The corpus luteum was found in 
the ovary of the opposite side; hence intraperitoneal transmigration of the ovum oc- 
curred. — (Howard Kelly.) 



£-~"Os 




Fig. 505. — Uterus Duplex Bicornis, with 
a Vagina Septa. The right uterus con- 
tained the product of conception and was 
6f inches (17 cm.) long; the left uterus was 
filled with decidua alone and was 4I inches 
(12 cm.) long. r, Right uterus; v, right 
vagina; *', intervaginal septum. — (Nagel*) 



Fig. 506. — Pregnancy with a Uterus 
Duplex. f The unimpregnated part 
caused an obstruction to labor. 



*Veit's "Handbuch d. Gyn.," Bd. 1, Fig. 119. 
f'Zeitsch. f. Geb. u. Gyn.," Bd. xiv, S. 169. 



CORNUAL PREGNANCY; MISSED LABOR. 



415 



subject to more complications during both pregnancy and labor than when 
the uterus is normal; they are more easily infected and fatal terminations are 
common. If the horn is well developed, delivery may be normal; but if the 
horn is rudimentary and there is no normal communication with the lower 
genital tract, the condition resulting is markedly like ectopic pregnancy (Figs. 
508 and 509). The symptoms, course, and treatment are then practically the 
same as in ectopic pregnancy. Kehrer, who collected and analyzed 82 cases 




Fig. 507. — Pregnancy in an Undeveloped 
Horn of a Uterus Bicornis. — (Werth.*) 




Fig. 50S. — Pregnancy in a Rudi- 
mentary Horn of a Uterus, 
showing the relation of the 
Round Ligament to the Gesta 
tion Sac. The Sac is Inside of 
the Round Ligament. — (Dakin.) 




Fig. 509. — Relations of the Sac of 
a Tubal Pregnancy to the Round 
Ligament. The Sac is Outside of 
the Round Ligament. — {Dakin.) 



from literature in 1900, states that expectancy is never indicated. Intervention 
should always be by Csesarean section after the thirty-second week. In Kehrer's 
study all the cases of labor in uterus duplex (Fig. 506) are recorded. The great 
majority are divided about equally between uterus unicornis bicollis and 
uterus bicornis unicollis (Fig. 504). A few cases occurred in uterus bicornis 
duplex (Fig. 506) and uterus septus bilocularis, but none whatever in any 
other varieties. 



XXII. MISSED LABOR. 

At full term ineffectual labor sets in, subsides, and the uterus remains un- 
emptied for months or even years; occasionally simple prolongation of preg- 
nancy, without any onset of labor occurs. A like condition is that of 
"missed abortion," when the fetus dies in the early months of gestation and 
remains in the uterus for weeks or months. 

Etiology. — This is obscure ; some variety of obstructed labor is usually present, 
such as tumors of the soft parts, exostoses or tumors of the bony pelvis, con- 
* "Arch. f. Gyn.," Bd. xvn, S. 281. 



416 PATHOLOGICAL PREGNANCY. 

tracted pelvis, cancer of the uterus, cicatricial bands of the cervix or vagina. 
The possibility of ectopic gestation, or of pregnancy in one horn of a bicornu- 
ate or unicornuate uterus, must be remembered (see pages 404, 414). 

Terminations. — The fetus always dies, and one of the following changes 
occurs: (1) maceration of soft parts and prolonged discharge from the cervix, 
with retention of the bones (page 305); (2) ulceration through the uterine wall 
into the vagina, rectum, or abdominal cavity; (3) septic metritis and fatal 
septicemia; (4) mummification; (5) calcification; (6) adipoceration ; (7) putre- 
faction. (Compare Death of the Fetus, page 304.) 

Treatment. — No pregnancy should be allowed to continue more than two 
weeks past the normal period of gestation, without a thorough examination 
as to the cause, with the aid of an anesthetic, if necessary. The treatment 
will depend upon the findings in this examination. If pregnancy be normal, 
labor should be at once induced; if ectopic or cornual, treatment should be 
along the lines laid down for those conditions. In cases in which weeks or months 
have elapsed and maceration or putrefaction of the fetus has occurred, in 
intrauterine pregnancy, the uterus should be emptied with all antiseptic pre- 
cautions, and in cases of uterine sepsis or perforation, hysterectomy is ad- 
visable. 



XXIII. SUDDEN DEATH IN PREGNANCY. 

Sudden death, directly attributable to pregnancy, appears, with few excep- 
tions, to be an impossibility; although the state of gestation is naturally able 
to influence unfavorably the prognosis of many serious affections, and thus to 
bring about sudden death indirectly, as in the case of cardiac valvular disease. 
Further, there are sudden affections which, while not peculiar to pregnancy, 
appear to be determined by the latter and may lead up to sudden death (acute 
yellow atrophy of the liver, impetigo herpetiformis). Finally, pregnancy does 
not appear to afford any immunity to sudden deaths from common causes, 
and the pregnant woman succumbs to apoplexy and the like, just as does the 
non-pregnant. Sudden death, absolutely referable to the pregnant state, 
could come only from eclampsia before delivery; from some mechanical result 
of the crowding of the viscera by the enlarged uterus (internal intestinal strangu- 
lation, etc.); from attempts at abortion, including the use of poisons; and, 
finally, from operative intervention. 



XXIV. INJURIES TO AND OPERATIONS UPON PREGNANT 

WOMEN. 

Injuries and Accidents. — Severe injuries do not necessarily result in a pre- 
mature interruption of pregnancy. The more common are those which cause 
a rupture of an enlarged blood-vessel of the external genitals or of the lower 
extremities. In a distended and varicose condition of the vessels of the 
vulva, the rupture of these vessels, owing to a fall from a bicycle, has resulted 
in almost fatal hemorrhage. In a case in private practice, I almost lost a 
patient from this cause; pregnancy was not disturbed. Many instances are 
recorded of the mother sustaining severe injuries by blows and falls, without 
pregnancy being interrupted. The abdomen itself has been torn open, and 



INJURIES AND PREGNANCY AFTER OPERATIONS. 417 

the fetus has even sustained fractures and traumata, and pregnancy has con- 
tinued. Extensive general burns, and severe local bruises and injuries of 
the vulva and pelvic floor, have not interfered with pregnancy. Spontaneous 
rupture of the uterus is one of the rarest accidents, and may be due to trau- 
matism, overdistention, a previous Caesarean section, or chronic inflammation. 
Again, traumatism may be an exciting cause of rupture, in the presence of 
hydramnios, chronic inflammation of the uterus, or weakening of the uterine 
walls by a previous hysterectomy. 

Penetrating Wounds of the Gravid Uterus. — This lesion is of very rare occur- 
rence. In 1899 * Estor and Pruech could find notes of but 40 cases in literature. 
The wounds were inflicted by cutting or pointed instruments, projectiles, the 
horns of animals, etc., and could be divided into incomplete, complete, and 
complicated. In the first-named the uterine wall was not completely pene- 
trated. Complete penetration has been extensive enough to permit the escape 
of the cord or even the fetus itself. In the complicated type other abdominal 
viscera were also wounded. The symptoms are those of shock and hemor- 
rhage with pain, escape of amniotic fluid, and prolapse of some of the contents 
of the uterus. Peritonitis resulted in a certain proportion of cases. About 
25 per cent, of the cases were fatal from shock, hemorrhage, or peritonitis. 
The complicated wounds have necessarily a graver prognosis. Laparotomy 
may be necessary for diagnosis, and certainly will be required for rational 
treatment with or without hysterectomy. 

Operations. — Surgical operations upon pregnant women are not only justi- 
fiable, but demanded, when delay until after confinement would seriously 
jeopardize the health or life of the patient. Under ordinary circumstances there 
is little danger of interrupting the pregnancy. Women of great nervous irrita- 
bility will sometimes prove the exception to the rule. The irritation produced 
by ulceration at the root of a tooth is usually more liable to interrupt a preg- 
nancy than the administration of nitrous oxide gas and the removal of the tooth, 
or the establishment of free drainage. The author has repeatedly had gas 
administered to patients for this purpose, and has never seen any bad results. 
Fibroid tumors, ovarian cysts, and the appendix are now frequently removed, 
without interrupting pregnancy, and for numerous other causes the abdomen 
has been opened and pregnancy has continued. Operations should not be 
performed at a period corresponding with the menstrual epoch, as abortion 
is then more apt to occur. For the same reason, it will be well to avoid the third, 
fourth, and eighth months. My opinion is that anesthetics in pregnancy are 
rather favorable than otherwise in their influence, when they decrease reflex 
irritation. 



XXV. PREGNANCY AFTER OPERATIONS INVOLVING THE 

GENITALS; PREGNANCY AFTER VENTROFIXATION AND 

VENTROSUSPENSION. 

See Pathology of Labor, Part V. 

* " Rev. de gynecol.," Nov., Dec, 1S99. 



27 



418 PATHOLOGICAL PREGNANCY. 



XXVI. FEVER OF PREGNANCY. 

This peculiar affection has been described by a number of authorities, 
including Tarnier and Ahlfeld. It occurs in two types, acute and subacute 
or chronic, which differ radically, and are held to be entirely separate condi- 
tions. Acute fever of pregnancy resembles such conditions as typhoid fever, 
septicemia, and acute miliary tuberculosis. Chronic fever of pregnancy appears 
to be a neurosis, with participation of the heat-center. Clinically it has been 
likened to a confirmed phthisis. From the facts that these febrile affections 
supervene without the least apparent cause, and subside immediately after 
the uterus is evacuated, they have received the designation "fever of preg- 
nancy." On account of the serious character of the symptoms, abortion has 
been performed a number of times. Had the correct diagnosis been made, 
no intervention would have resulted. Kleinwachter is opposed to the use 
of the term "fever of pregnancy," or including the condition among the 
indications for terminating pregnancy. 



XXVII. THE METRORRHAGIA OF PREGNANCY; ANTE-PARTUM 

HEMORRHAGE. 

A discharge of blood from the vagina during pregnancy naturally suggests 
threatened or inevitable abortion (Fig. 511), or placenta praevia, and should 
always receive careful attention. There are various other causes of hemorrhage, 
however, which should not be forgotten. They will be discussed here chiefly 
with reference to the diagnosis; the treatment, when of obstetric importance, 
being considered elsewhere. (1) In cervical endometritis, or cervical catarrh, the 
vaginal mucus may be stained with blood, but the amount is usually slight; the 
cervix will be found larger than normal, with perhaps pouting of the lips, erosions 
of the mucous membrane, and follicular degeneration;' the outer lips of the ex- 
ternal os having a velvety feeling. There is follicular degeneration, and little 
nodules, like shot, can be felt by the examining finger; a discharge from the 
cervix, mucous or muco-purulent, is present, perhaps tinged with blood. There 
is more or less pain in the back and pelvis, constipation and vesical irritation, 
and probably a history of pelvic trouble antedating pregnancy. (2) In eroded 
cervix, or cervical erosions so called, there are patches of bright red, granular 
mucous membrane, which were formerly erroneously supposed to be ulcers; 
they readily bleed upon pressure. (3) With lacerated and eroded cervix, 
the infection of a cervical tear is a common cause of cervical endometritis. 
In these cases there will be considerable cervical hypertrophy, with the other 
evidences of cervical inflammation. A laceration may be mistaken for an 
erosion, but if the edges are drawn together the redness will disappear; this,. 
of course, cannot be done in the case of an erosion. A very common cause is gon- 
orrhea; the condition is also often due to infection of a cervical laceration, and 
may be caused by retroversion. (4) Persistence of menstruation is a rare condi- 
tion. In many of the recorded cases, the hemorrhage has been probably due 
to placenta praevia or other causes. The diagnosis must rest on the monthly 
occurrence of the flow and upon the exclusion of other sources of hemorrhage 
(Fig. 510). (5) Hemorrhoids of the vagina, ostium vaginas, or vulva have 



METRORRHAGIA OF PREGNANCY. 



419 




Fig. 510. — The Metrorrhagia of Pregnancy. Menstruation Occurring in the 

Early Weeks. 




Fig. 511. — The Metrorrhagia of Pregnancy. Hemorrhage caused by the separation 
of the decidua vera from the uterine wall in threatened or inevitable early abortion. 



420 



PATHOLOGICAL PREGNANCY. 



already been discussed. In rare instances, and usually as the result of trau- 
matism, rupture may occur, giving rise to severe hemorrhage, which requires 
suture. The diagnosis is made by inspection. (6) Hemorrhage may be due to 
separation of a placenta praevia, or of a normally situated placenta (see pages 

225 and 237) (Fig. 512). (7) An 
intracervical polyp sometimes oc- 
curs as a complication of gesta- 
tion, and causes persistent hemor- 
rhage; the diagnosis is made by 
inspection. If there is much pro- 
trusion of the polypus the diagnosis 
will not be difficult. In some cases, 
however, it is very likely to be con- 
founded with abortion, the poly- 
pus being mistaken for the intact 
ovum. The history of the case 
before pregnancy may be of assist- 
ance. (8) Cancer of the cervix 
may be a cause of hemorrhage 
during pregnancy, and has been 
mistaken for placenta praevia. The 
diagnosis will rest upon the char- 
acteristic cauliflower appearance, 
when it is present; upon the fetid 
discharge; and upon the exclusion 
of other sources of hemorrhage, 
such as placenta praevia, cervical 
erosions, and cervical polypus. 
The diagnosis must, of course, be 
confirmed by microscopic examina- 
tion. (9) Malignant disease of the 
vagina is not common, and when 
it does occur is usually secondary 
to cancer of the cervix. Hemor- 
rhage and a foul-smelling discharge 
are common symptoms. There 
may be a papillary swelling of the 
posterior wall, or the vaginal walls may be generally infiltrated and the vagina 
constricted. The inguinal glands are usually infiltrated, (to) Apoplexy of the 
placenta has already been discussed; if slight hemorrhage occurs and placental 
apoplexy is suspected, the treatment is, of course, that of threatened abortion 
(see page 400). 




Fig. 512. — The Metrorrhagia of Pregnancy. 
Internal concealed hemorrhage from the sepa- 
ration of a normally situated placenta, and 
also hemorrhage from the separation of a 
central placenta praevia. 



PART FOUR. 

Physiological Labor* 



I. THE PASSAGES. 1. The Bony Pelvis. (1) The Bones. (2) The Pelvic 
Joints. (3) External Surface of Pelvis. (4) Internal Surface of Pelvis. 
(5) The False Pelvis. (6) The True Pelvis. (7) The Pelvic Inlet. (8) 
The Pelvic Cavity. (9) Pelvic Outlet. (10) Table of Pelvic Measure- 
ments, (a) External; (b) Internal. (11) Pelvic Planes, (a) Inlet; 
(b) Cavity; (c) Outlet. (12) Pelvic Axes, (a) Inlet; (b) Cavity; (c) 
Outlet. (13) Comparison of Different Pelvic Diameters, Circumferences, 
Planes and Angles. (14) Factors Influencing Size and Shape of Pelvis: 
(1) Individual; (2) Sex; (3) Age, Infantile and Antepubic. (15) Functions. 

2. The Soft Tissues of the Pelvis. Soft Parts. (1) Muscles. Psoas 
Majus, Psoas Parvus, Uiacus, Levator Ani, Pyriformis, Coccygeus, Obtur- 
ator Internus, Bulbo-cavernosus. (2) Ligaments, (a) Great Sacro-sciatic ; 
(b) Small Sacro=sciatic. (3) Pelvic Cellular Tissue. (4) Blood=vessels 
and Lymphatics. (5) Nerves. 3. The Parturient Tract. 

II. THE FETUS. 1. The Fetal Head. (1) Introduction. (2) Regions and 
Protuberances. (3) Bones. (4) Sutures. (5) Fontanelles. (6) Move- 
ments upon Spinal Column. (7) Complete Flexion. (8) Incomplete 
Flexion. (9) Complete Extension. (10) Incomplete Extension. (11) 
Rotation. (12) Moulding. (13) Diameters. (14) Planes and Cir- 
cumferences. 2. The Fetal Trunk. (1) Shape. (2) Measurements. 

3. Attitude or Posture. Fetal Ovoid or Ellipse. 4. Presentation. 

(1) Shape of Uterine Cavity. (2) Shape of Fetal Ellipse. (3) Uterine Con- 
tractions. (4) Mobility of Head. (5) Direction of Uterine Force. (6) 
Gravity. (7) Reflexion. 5. Position. (1) Flattened Shape of Fetal 
Ovoid. (2) Shape of Uterine Cavity. (3) Axial=torsion of Uterus. (4) 
Shortening of Left Oblique Diameter of Pelvis by Sigmoid and Rectum. 

(5) Diminution of Transverse Diameter by Muscles. (6) Greater Roomi- 
ness of Right Oblique Diameter. 

III. EXPELLING FORCES. 1. Voluntary or Auxiliary Forces. 2. Involun- 

tary Forces or Uterine Contractions. 3. Strength of Uterine Con- 
tractions. 

IV. ETIOLOGY OF LABOR. 

V. THE STAGES OF LABOR. 1. Preparatory Stage. (1) Sinking of Uterus. 

(2) Gradual Shortening of Cervix and Dilatation. (3) False or Spurious 
Labor Pains. 2. First Stage or Stage of Dilatation or Dilatability. 
(1) True Uterine Contractions. (2) Muco=sanguineous Discharge. (3) 
Mechanism of Cervical Dilatation. (4) Formation of Caput Succedaneum. 
3. Second Stage or Stage of Expulsion. (1) Characteristic Uterine 
Contractions. (2) Use of Voluntary Forces. (3) Descent of Presenting 
Part. (4) Dilatation of Vagina. (5) Dilatation of Vulva. (6) Expulsion 
of Fetus. 4. Third Stage or Stage of Placental Delivery. (1) Char- 
acteristic Uterine Contractions. (2) Control of Hemorrhage. (3) Separa- 
tion of Placenta. (4) Expulsion of Placenta. 

VI. THE MECHANISM OF LABOR. 1. Definition. 2. Importance. 3. Six 
Stages. (1) Moulding. (2) Engagement and Descent. (3) Rotation 
of the First Part of the Fetal Ellipse. (4) Expulsion of the First Part 
of the Fetal Ellipse. (5) Rotation of the Second Part of the Fetal Ellipse. 

(6) Expulsion of the Second Part of the Fetal Ellipse. 

VII. THE DURATION OF LABOR. 
VIII. LIVE BIRTH. 
IX. FEIGNED DELIVERY. 



X. UNCONSCIOUS DELIVERY. 

XI. VERTEX PRESENTATIONS. 1. Definition. 2. Frequency. 3. Etiology. 
4. Positions and Relative Frequency. 5. Mechanism, (l) Flexion 
and Moulding. Caput Succedaneum. (2) Engagement and Descent. 
(3) Anterior Rotation of Occiput. (4) Extension and Expulsion of the 
Head. (5) Rotation of the Trunk and Restitution of the Head. (6) 
Expulsion of the Trunk. 6. Diagnosis. 7. Prognosis.. 

XII. MANAGEMENT OF LABOR. 1. Introduction. Prophylaxis in Obstetrics. 
Hygiene of Pregnancy. Response to Summons. 2. Preliminary Prep- 
arations. (1) The Obstetric Outfit. (2) Mother's Outfit. (3) Baby's 
Outfit. (4) Physician's Obstetric Bag. (5) The Obstetric Nurse. Rules. 
(6) The Lying-in Room. (7) The Labor Bed. (a) Permanent Bed ; (b) 
Temporary Bed ; (c) Arrangement of Double Bed. 3. Preparation of 
the Physician. (1) Previous Septic Contact. Gloves. (2) Personal 
Cleanliness. (3) Obstetric Asepsis. (4) Operating Suit. (5) Hand Lubri- 
cants. 4. Preparation of Patient. (1) Enema. (2) Pubic Hair. (3) 
Antepartum Bath. Local Antisepsis. (4) Antepartum Douche. (5) Vulvar 
Dressing. 5. The Examination of Labor. (I) Posture of Patient. (2) 
Obstetric Prognosis. 6. Management of the First Stage. (1) Posture 
of Patient. (2) Presence of Physician. (3) Attention to Bladder and Rec- 
tum. (4) Food, Drink, Sleep. (5)|Use of Voluntary Forces. (6) Care of 
Membranes. (7) Anesthesia. (8) Repetition of Vaginal Examinations. 
7. Management of Second Stage. (1) Posture of Patient. (2) Presence 
of Physician. (3) Attention to Bladder and Rectum. (4) Food, Drink, 
Sleep. (5) Use of Voluntary Forces. (6) Care of Membranes. (7) Anes- 
thesia. (8) Repetition of Vaginal Examinations. (9) Perineal Protection. 
(10) Cleansing of Eyes and Mouth. (11) Care of Cord about Neck. (12) 
Shoulder Delivery. (13) Delivery of Trunk. (14) Following down Fundus. 
(15) Posture of Child in Bed. (16) Establishment of Respiration. (17) 
Ligation of Cord. (18) Care of Cord. (19) Silver Solution for Eyes. (20) 
Handling Child. (21) Protection of Child from Cold. (22) Prevention of 
Hemorrhage. (23) Inspection and Repair of Perineum. 9. Management 
of Third Stage. (1) Prevention of Hemorrhage. (2) Temporary Vulvar 
Dressing. (3) Delivery of the Placenta. (4) Postpartum Douche. (5) 
Ergot. (6) Inspection and Repair of Perineum. (7) Cleansing of Patient 
and Bed. (8) Abdominal Binder. (9) Permanent Vulvar Dressing. (10) 
Nourishment. Rest. Sleep. (11) The Physician's Hour. 



Labor is the physiological end of pregnancy, and may be defined as the pro- 
cess by which the fetus and its appendages are separated from the mother. 
All labors are classified as either normal or abnormal, or, as they are here desig- 
nated, physiological and pathological labors. Normal or physiological labor 
is the delivery of a living child with the vertex presenting, by the natural forces, 
and without complication in any of the three stages. Should the fetus be 
still-born, its death having occurred either just previous to or during the labor, 
but not being directly due to the labor, the labor would still be within the limits 
of normal. Vertex presentation is the most frequent, it gives the lowest mor- 
tality rate, and labor is more easily and quickly terminated by this than by 
any other presentation. The three factors concerned in any variety of labor 
are: (i) the passages; (2) the fetus; (3) the forces. 



I. THE PASSAGES. 

1. THE BONY PELVIS. 

Introduction and Definitions. — A knowledge of the female bony pelvis 
is the very alphabet of obstetric science and the foundation of obstetric art. 
This structure is most important, since it is from the disproportion between 
its size and that of the fetus or from its abnormal shape that many of the diffi- 
culties during labor arise. The derivation of the term is from the Greek word 
TreAt'c, "a bowl," from its fancied resemblance to that ancient utensil once 
used by barbers ; or it may be because it plays the part of a reservoir for certain 
temporary secretions. It is that part of the trunk which forms the lower 
abdominal boundary, and in the adult it is situated near the middle of the 
body. It transmits to the lower extremities the weight which it receives from 
the head and the rest of the trunk; it is supported anteriorly by the femora; 
it is open above and below and is a bony, irregular, roomy, and conoidal shaped 
cavity or canal. The anatomical pelvis is composed of four bones: the two 
ossa innominata, the sacrum, and the coccyx. The obstetric pelvis includes, 
besides these bones just mentioned, the last lumbar vertebra. This description 
designates the static pelvis, but there are other parts to be considered in 
the dynamic pelvis — that seen in the living subject and in labor. These are 
the soft parts which form its floor and extend the parturient canal. It will be 
seen from this statement that the obstetrician must recognize and be familiar 
with two pelves, the one bony and stable, the other soft and pliable. The 
former is passive, the latter active. The most important parts of the pelvis, 
obstetrically, are the inlet and the outlet. 

The Bones (Ossa Innominata, Sacrum, Coccyx). — The anterior and lateral 
walls of the pelvis are formed by the ossa innominata. Each os innominatum or 
hip-bone is shaped like a stretched-out quadrangle, constricted and twisted 
in the middle, by which means the two parts of the bone are brought into differ- 
ent planes (Fig. 513). The hip-bone is composed of: (1) the ilium; (2) the 

423 



424 



PHYSIOLOGICAL LABOR. 



ischium; (3) the pubis. It is not till the eighteenth or twentieth year that 
the several parts of the acetabulum are firmly joined. A faint white line marks 
the junctions. The sacrum forms the larger part of the posterior pelvic wall. 
It is shaped like a pyramid with the base at the upper part, and is composed 
of four vertebras. The term is derived from sacer, "sacred," because it helps 
protect the genitals, which were held to be sacred, or because it was offered 
in sacrifice. The coccyx — so named because it was thought to look like the 
cuckoo's beak — comprises five rudimentary vertebrae. It is shaped like a 
triangle and has its base pointing upward. If a bony union is established 
between the sacrum and coccyx, it may offer an obstacle to labor; normally 
the coccyx remains movable until middle life. It represents the tail appendage 
in vertebrates. 




Fig. 513. — Female Bony Pelvis. 



I ^The Pelvic Joints. — The articulations of the female pelvis differ somewhat 
from those of the male pelvis, as those of the former are peculiarly adapted 
to the process of labor. By their existence the pelvis is possessed of a certain 
amount of mobility between its several parts. These articulations number 
seven — one pubic, two sacro-iliac, three sacro-lumbar, and one sacro-coccygeal. 
Five of these articulations are amphiarthrodial, much like those between the 
bodies of the vertebrae. 

Pubic Joint or Symphysis Pubis. — The pubic joint or "symphysis" pos- 
sesses fibro-cartilages similar to the intervertebral discs, each of which is firmly 
attached to the corresponding pubic bone. This cartilage is soft in the center 
and firmer at the outside; thicker in front than behind, and thicker in females 
than in males. Many assert the presence of a synovial membrane,* though 
Morris, Depaul, and French authorities generally deny its. existence save in 

* Allen. 



THE PELVIC JOINTS. 



425 



exceptional cases. There are, besides, four ligaments — a posterior, a superior, 
an anterior, and an inferior sub-pubic or ligamentum arcuatum. By the last 
the pubic arch is filled out and made smooth and rounded. These structures 
are of as great importance at the outlet as the sacro -vertebral angle is at the 
inlet (Fig. 517). In the pregnant woman the symphysis together with the 
other joints becomes more movable. The softening of pregnancy gives rise 
to a slight gliding movement. The connected surfaces are practically not 
separated, as, indeed, this separation would have to be considerable to increase 
the ant ero -posterior diameters to any extent. 

Following the investigations of Budin, I have made examinations of several 
hundreds of pregnant women in three maternity services, over a period of 
ten years, in order to ascertain if there were movements in the pubic articu- 




Fig. 514. — Male Bony Pelvis. 



lation. The finger was inserted into the vagina, the ball of the finger placed 
directly against the lower margin of the symphysis pubis, and then the woman 
was asked to walk or stand first on one and then the other leg. The side 
of the pubis corresponding to the free leg was found to descend, while the bone 
on the other side remained fixed. I concluded that there is invariably present 
in this joint a certain amount of mobility which increases with the advance 
of pregnancy and with the number of pregnancies, and when present to a 
considerable degree the subjects have no difficulty in walking; the mobility 
is very slight in primigravidae. (See page 117.) 

Sacro-iliac Joints. — The sacro-iliac articulation joins the lateral surfaces 
of the sacrum and ilium. The bare surfaces of both bones are rough, but are 
covered by thin layers of cartilage, the one on the ilium being the thinner and 



426 PHYSIOLOGICAL LABOR. 

consisting of fibro-cartilage; that on the sacrum, of cartilage, which lies next 
to the bone, and beyond which comes fibro-cartilage. Some anatomists, 
among whom is Luschka, believe that there is also a synovial membrane, espe- 
cially marked in pregnancy. Morris does not hold this view; at least he does 
not believe the synovial membrane to be constant, although it is more apt 
to be present in the female than in the male. There are, besides, six ligaments' 
to make the joint firm. In normal labor the only movement worthy of mention 
in these joints is a gliding one, and by it the antero-posterior diameter of the 
pelvic outlet is somewhat increased. Sappey believes that these articulations 
are midway between movable and semi-movable joints, although it is generally 
held that they are amphiarthrodial. In five symphyseotomies I obtained 
from two to two and a half inches separation at the pubis, and subsequent 
strong fibrous union in each case without apparent injury to the ligaments 
of the sacro-iliac joints. This proves the existence of a certain amount of 
motion at these joints, and also of considerable stretching of the anterior liga- 
ments. 

Matthews Duncan taught, and I believe it has been proved clinically, 
that the movements taking place in the sacro-iliac joints during labor are 
important to its progress. There is an elevation and depression of the pubis, 
or diminution and increase of pelvic inclination; or, from another point of view, 
if the sacrum is considered as the bone that moves, it oscillates in an imaginary 
transverse axis which passes through the lower part of the second sacral 
vertebra, so as to increase the pelvic inlet or outlet. That any great movement 
can occur between the ilium and sacrum is scarcely possible ; for they are fixed 
in one position by (i) their shape, one being dovetailed into the other; (2) 
by the ligaments proper of the sacro-iliac joint; (3) by the sacro-sciatic liga- 
ments; and (4) by the ilio-lumbar ligaments. The very shape of the sacrum 
prevents any extensive movement of that bone upon the ilium. Nature has 
provided for the increase of the coccygo-pubic diameter in the movable articu- 
lation of the coccyx with the sacrum, and this is usually more than sufficient 
without any accompanying rotation of the latter. (Compare Posture in Ob- 
stetrics.) 

Sacro-vertebral Articulation. — The union between the sacrum and the last 
lower lumbar vertebra is like that between the other vertebrae. The pecu- 
liarity of this joint is that the interarticular disc of cartilage is just twice as 
thick in front as behind, thus forming what is termed the "sacro-vertebral 
angle" (Fig. 518). The "pelvic inclination," while it depends in a great measure 
upon the angle thus formed, yet is produced in part also by the obliquity of 
the innominate bones to the sacrum. As stated before, the union between the 
vertebral bodies is amphiarthrodial, while that between the apophyses is ar- 
throdial. 

Sacro-coccygeal Joint. — The most movable joint is the sacro-coccygeal 
joint, and is considered a part of the pelvic floor. It has two articular sur- 
faces, an interosseous fibro-cartilage, and four peripheral ligaments. Before the 
intercoccygeal articulations are ankylosed, they are symphyses, and some claim 
that motion exists between the different coccygeal bones as well as between 
the coccyx and sacrum. Firm union between the coccyx and sacrum occa- 
sionally occurs even in young subjects, but is most often found in elderly pri- 
miparae. Generally, however, during the exit of the head the coccyx is pushed 
back, and by this means the antero-posterior diameter of the outlet is increased 
to the extent of one inch. 

Functions of the Pelvic Joints. — In an obstetric sense the pelvic joints are 



SURFACES OF THE PELVIS. 



427 



designed by nature not so much to increase the diameters of the pelvis by 
the swelling they undergo in pregnancy and by the slight movements occurring 
in them as they are to act as cushions to lessen jars and shocks that might 
be transmitted to the spinal cord, uterus, or fetus, from blows, falls, and trau- 
matisms in general. The greatest mobility is exerted at the sacro-coccygeal 
joint, less at the pubic, and least at the sacro-iliac. The sacrum can move 
in an antero-posterior diameter, making a swing of 1 cm. for the promontory. 
This is most marked when the woman is on her back with her legs hanging 
over the edge of the table, the attitude known as " Walcher's hanging position." 
(See Part X, Posture in Obstetrics.) 

External Surface of the Pelvis. — The difference in completeness between 
the anterior and posterior parts of the pelvis is most striking. The pelvic 
wall is unbroken behind from the beginning of the last lumbar vertebra to 
the tip of the coccyx, while in front there is a great gap both above and below 




Fig. 515. — Posterior View of Female Bony Pelvis. 



the pubic articulation. On either side is the ischio-pubic foramen, which 
is covered by membrane, and over the membrane is the obturator externus 
muscle (Fig. 531). The sacrum and coccyx taken together form the chief 
part of the posterior portion of the pelvis, and the bony mass is triangular in 
shape with the apex downward. The sacral crest is in the median line. The 
sacro-lumbar muscles fill in the furrows which are formed on both sides of the 
iliac tuberosities, and between these and the sacral crests, and at the outer side 
of each, open the posterior sacral foramina (Fig. 515). 

Internal Surface of the Pelvis. — The bony pelvis may be regarded as a 
cylinder, contracted near its middle by the circumference of the pelvic inlet, 
which divides it into a false pelvis above and a true pelvis below. In contrast 
to the rough and irregular external surface, the internal surface of the pelvis 
is smooth and symmetrical, and is clearly divided into the two parts mentioned 
above. The cavity of the pelvis may be considered to be an inverted, trun- 
cated cone. The dividing-line consists of the ilio-pectineal line, supplemented 



428 



PHYSIOLOGICAL LABOR. 



by the superior anterior margin of the sacrum and its alas, or the boundary- 
line is the circumference of the pelvic inlet (Fig. 516). 

The False Pelvis. — The false, superior, or large pelvis is bounded behind 
by the last lumbar vertebra and the ilio-lumbar ligaments; on the sides by 




Acetabulum. 



/schial 



Fig. 516. — Transverse Section through the Acetabula and Ischial Tuberosities, 
showing Posterior Portion of the Internal Surfaces of the False and True 
Pelvis. 



Part of linea alda 

Righ t rectus muscle 



the iliac bones; in front there is a gap filled up in the recent state by the elastic 
lower abdominal wall. If the convergence of the bony walls of the false pelvis 
were continued downward, they would meet at a point corresponding with 
the fourth sacral vertebra. It is from this fact that the false pelvis has often 

been compared to a funnel. 
The false pelvis really be- 
longs to the abdominal 
cavity, and to its contents 
it offers protection and 
support ; it has no marked 
obstetric value. In multi- 
gravidous women the iliac 
fossa serves to support the 
fetal head. It forms an 
inclined plane which serves 
as a guide to the fetus and 
directs it downward when 
impelled by contractions 
of the uterus, and thus 
aids its engagement in the 
pelvic inlet; and not unless 
it be very much deformed will it obstruct the passage of the child. 

False Pelvis and External Measurements. — (Compare Pelvimetry, page 169.) 
( 1 ) The anterior inter spinous diameter or the widest distance between the anterior 
iliac spinous processes is 10 inches (25.5 cm.). It is measured by placing the 
points of the pelvimeter upon the external surfaces of the spines. (2) The 




Fig. 



517. — Anterior Portion of the Internal Sur- 
face of the Pelvis. 



THE FALSE AND TRUE PELVIS. 



429 



intercristal diameter, or the widest interval between the iliac crests, is u inches 
(28 cm.). It is measured by placing the points of the pelvimeter upon the 
most prominent portions of the iliac crests. (3) The right external or diagonal 
oblique is 8| inches (22 cm.). It is measured from the right posterior superior 
spinous process of the ilium to the left anterior superior spinous process. The 
posterior spinous process may be recognized by the distinct indentation under- 
lying it. (4) The left external or diagonal oblique is also 8f inches (22 cm.). 
It is measured from the left posterior superior spinous process of the ilium 
to the right anterior superior spinous process. (5) The posterior interspinous 
diameter is 3! inches (8.89 cm.) and is the greatest distance between the pos- 
terior superior spinous processes of the ilium. (6) The bitrochanteric diameter 
is 12^- inches (31 cm.). It is the greatest distance between the external sur- 
faces of the great trochanters. (7) The bis -ischial diameter is 4^ inches (11 cm.). 




Fig. 518. — Sagittal Section through the Middle of the Sacrum and Pubic Joint 
showing the Internal Lateral Surfaces of the False and True Pelvis. — 
{From the author's aluminium cast of a female pelvis.) 



It is the greatest distance between the external surfaces of the ischial tuber- 
osities. This must be compared with the transverse diameter of the outlet 
(page 434). (8) The external circumference of the pelvis is 35.5 inches (88.75 
cm.), and is measured by passing a tape-measure about the pelvis over the 
symphysis, just below the iliac crests, and across the middle of the sacrum. 

Although these measurements vary to some extent with the individual, 
any wide difference would indicate pelvic deformity. 

The True Pelvis. — The true, inferior, or small pelvis is that part below the 
ilio-pectineal line, and it forms the true obstetric pelvis (Fig. 516). The true 
pelvis in the female is much larger than that in the male. It is bounded poste- 
riorly by the concavity of the sacrum; on the sides by the sacro-sciatic liga- 
ments and the internal surfaces of the acetabula and obturator membranes ; 
anteriorly, by the pubic bones and obturator membranes. If any horizontal 
plane of this curved cylinder — the true pelvis — is taken at a level, the bony 



430 



PHYSIOLOGICAL LABOR. 




wall is incomplete. In any plane that may be selected there will be a foramen 
covered by membrane or by distensible and elastic muscular or fibrous tissue ; 
or a movable joint such as the coccyx directly opposite the solid mass of the 
pubic bones ; or some elastic tissue that will permit of considerable compression 
without injury. The conclusion to be drawn from this fact is that although 
the fetus must pass through this bony cylinder to reach the external world, 
yet by the peculiar formation of the pelvis both the fetus and the mother's 

soft parts are protected against too great 
or too prolonged pressure; while if con- 
cussions should occur, their effect would 
be much alleviated. 

The Pelvic Inlet. — The pelvic inlet, 
superior strait, brim, margin, isthmus, 
linea terminale, linea ilio-pectinea, is the 
entrance to the cavity of the true pelvis. 
The superior strait and the inferior strait 
received their names because they were 
thought to be more contracted than the 
space which lies between them. I prefer 
the term pelvic inlet. The anatomical 
inlet is the entrance of the small or true 
pelvis, and corresponds to the upper mar- 
gin of the symphysis pubis, and to the edges 
of the bones extending backward to the 
sacral promontory (Fig. 520). The obste- 
tric inlet is the least available space at the 
upper portion of the pelvic canal; it is 
bounded by a line passing J- inch (1 cm.) 
below the upper margin of the sym- 
physis pubis, along the posterior margin 
of the oblique rami and body of the pubis, 
past the ilio-pectineal eminences, the an- 
terior margin of the sacral alae, and the 
summit of the sacral promontory. 

Shape. — The shape of the inlet in the 
bony pelvis is that of a curvilinear tri- 
angle with the base behind and the apex 
in front, the chief irregularity being found 
in the sacral promontory. It is here that 
pelvic deformities cause by far the greatest 
trouble, and hence an intimate knowledge 
of the pelvic inlet is necessary (Fig. 520). 
Pelvic Inlet Measurements. — (Compare 
Pelvimetry, page 173.) (1) The antero- 
posterior diameter, or true conjugate, or diameter conjugata vera (C. V.), 
is 4^ inches (11.25 cm.). It is measured from the middle of the sacral pro- 
montory to the point on the upper border of the symphysis pubis crossed by 
the linea terminalis, and is the least distance between the posterior surface 
of the pubic symphysis and the sacral promontory, or it is the available antero- 
posterior space at the inlet for the passage of the fetus. The anterior extremity 
of the true conjugate usually ends on the posterior surface of the pubic sym- 
physis, about f inch (2 cm.) below the brim (Fig. 519). (2) The anatomical 




Fig. 519. — Vertical Mesial Section 
of a Female Pelvis showing the 
l/umbo-sacro-coccygeal curve, 
the Inclination and Shape of the 
Symphysis, the Relations of the 
Anatomical, Obstetric, and Diag- 
onal Diameters of the Pelvic 
Inlet, and the Sacro-pubic and 
Coccygo-pubic Diameters of the 
Pelvic Outlet. The Lower Fig- 
ure shows the Pubic Arch. — {From 
the author's lead-tape tracings.) 



PELVIC INLET AND PELVIC CAVITY. 



431 



conjugate or the sacro-suprapubic diameter ends at the superior margin of the 
symphysis and is longer than the true conjugate by \ inch (0.63 cm.) (Fig. 
5 I 9)- (3) The diagonal or indirect conjugate, or diameter conjugata diagonalis 
(C. D.)i is $i inches (13.5 cm.), or about f inch (2 cm.) greater than the true 
conjugate, and is the distance from the middle of the promontory of the 
sacrum to the under surface of the sub-pubic ligament. (See Pelvimetry, 
Part II.) (4) The external conjugate, or the diameter of Baudelocque, is 8 
inches (20.3 cm.), or 3^ inches (8.75 cm.) more than the true conjugate. It is 
measured from the upper external edge of the symphysis pubis, by means of a 
pelvimeter, to the depression under the spine of the last lumbar vertebra, 
which is a point about one inch above the posterior interspinous diameter 
(Fig. 211). (5) The transverse, bis-iliac, or diameter transversa (T), is 5 + inches 




SYMPHYSIS. 

t 

Fig. 520. — The Superior Surface of the Pelvis showing the Shape and Diameter s 

of the Pelvic Inlet. 



(13.5 cm.). It is measured between the most distant points of the ilio- 
pectineal lines (Fig. 520). (6) The right oblique, first oblique, or diameter 
diagonalis dextra (D. D.), is 5 inches (12.5 cm.). It is measured from the 
right sacro-iliac synchondrosis to the left pectineal eminence (Fig. 520). (7) 
The left oblique, second oblique, or diameter diagonalis lasva (D. L.), is 5 inches 
(12.5 cm.). It is measured from the left sacro-iliac synchondrosis to the 
right pectineal eminence (Fig. 520). The two oblique diameters join the four 
cardinal points of Capuron: viz., the right sacro-iliac symphysis with the left 
pectineal eminence, and the left sacro-iliac symphysis with the right pectineal 
eminence. On the continent of Europe, — namely, in France and Germany, — 
and also in America, the right oblique diameter of the pelvic inlet is named 
from the right sacro-iliac synchondrosis, and the left from the left. In Eng- 
land, on the contrary, the reverse obtains; namely, the right oblique diameter 



432 



PHYSIOLOGICAL LABOR. 



of the inlet ends at the right ilio-pectineal eminence, and the left is that which 
ends at the left ilio-pectineal eminence. (8) The circumference of the pelvic 
inlet is 1 6 inches (40.5 cm.). 

Obstetric Landmarks of the Inlet. — (1) The symphysis pubis in front; (2) 
just posterior on either side, situated upon the pubic bone, close to the ilio- 
pubic junction, is found a rough eminence — the ilio-pectineal eminence; (3) 
the boundary -line of the inlet on either side, known as the linea terminalis; 
or more commonly, from its source of origin, as the ilio-pectineal line; (4) 
the points on the sacro-iliac joints at which the linea pectinea joins them; 
(5) the promontory of the sacrum or the sacro- vertebral angle. The inter- 
vertebral cartilage between the sacrum and last lumbar, being wedge-shaped 
and thicker in front, forms an angle between the sacrum and vertebral column 
and causes the inclination of the pelvis. 

The Pelvic Cavity. — The pelvic cavity, pelvic canal, excavation, small or 




Fig. 521. 



-Transverse Section through the True Pelvis Just below the Pelvic 
Inlet and Parallel to it. — {Author's collection.) 



true pelvis, is the portion bounded by the inlet above, the outlet below, in 
front by the symphysis pubis, at the sides by the innominate bones, and behind 
by the hollow of the sacrum and the coccyx. The pelvic cavity is irregularly 
barrel-shaped or cylindrical. It must never be forgotten that the pelvis offers 
a curved and not a straight cylinder to deal with — a cylinder bent upon itself, 
so to speak. If this fact be overlooked, the most important factor in deter- 
mining the mechanism of delivery is ignored. This cavity may be conveniently 
separated into four regions: anterior, posterior, and two lateral (Figs. 516 
to 518). The anterior region has a marked notch in the pubic arch. The 
surface is convex from above downward, and concave from side to side. In 
the middle of this region the posterior part of the articulation of the symphysis 
pubis projects vertically and makes a prominence of from J to J of an inch 
(0.63 to 1 cm.). Toward the sides the surface is smooth, and then come the 



PELVIC OUTLET. 



433 



internal obturator or sub-pubic fossae. The posterior region consists of the 
surfaces of the sacrum and coccyx. This part is concave from above down- 
ward, the curve being deepest at the junction of the second and third sacral 
vertebrae. Down to this point the curve is very flat; which makes the axis 
of the cavity straight above this level. The lateral regions consist of two 
well-defined parts; the anterior being entirely bony and corresponding to the 
posterior part of the acetabula and to the ischial body and tuberosity; and 
its direction is from above downward, from without inward, and from behind 
forward. The posterior part consists for the most part of the internal 
face of the sacro-sciatic ligaments and foramina. The direction of this part is 
the converse of the anterior, it being from above downward, from without 
inward, and from before backward. 

Pelvic Cavity Measurements. — (Compare Pelvimetry, page 173.) (1) The 
antero-posterior diameter — from the middle of the pubic joint to the middle line 
uniting the second and third pieces of the sacrum — measures 5 inches (12.5 cm.). 
(2) The transverse diameter — a line on the same level — is 4I inches (12 cm.) 
in length. (3) The oblique — from the middle of the great sciatic foramen 
to the middle of the ischio-pubic foramen — is 4I inches (12 cm.) long. 

The depth of the pelvis at the symphysis is if inches (4 cm.). The depth of 
the lateral wall over the smooth surface of the ischial bones is 3^ inches (9 cm.). 
The depth of the posterior wall, following the course of the sacrum and coccyx 
from promontory to tip of coccyx, is \\ to 5 inches (11.5 to 12.5 cm.). 

The obstetric landmarks of the cavity are as follows: (1) The pubic joint 
in front; (2) the obturator foramen; (3) the spine of the ischium; (4) the 
great sacro-sciatic ligament and foramen; (5) the small sacro-sciatic ligament 
and foramen; (6) the sacrum and coccyx. 

The Pelvic Outlet. — The pelvic outlet or inferior strait is the lower opening 
of the cavity of the true pelvis (Fig. 522). While there is at the pelvic inlet 
a continuous ring of bone, the circumference of the pelvic outlet is partly bony 
and partly ligamentous, and there are, besides, certain projections not found 
at the inlet; namely, the spines and tuberosities of the ischia separated by 
notches, and certain indentations also, the most important being the pubic 
arch. The anatomical outlet is the real outlet of the true pelvis and is bounded 
behind by the coccyx; in front by the sub-pubic ligament; on the sides by 
the ischio-pubic rami, the ischial tuberosities, and the greater and lesser sciatic 
ligaments. The obstetric outlet is just above this, and is the circumference 
of greatest bony resistance of the true pelvis as well as the smallest in size. 
It is bounded by the posterior surface of the symphysis pubis about J inch 
(0.625 cm.) above the lower margin; the upper portions of the ischial tuber- 
osities and the lower border of the sacrum. 

Shape. — Its shape is that of a diamond or of two triangles having a common 
base, and varies with the mobility of the coccyx, and in labor it becomes almost 
circular, thus being more changeable than the pelvic inlet. In the sitting 
posture the weight of the body rests entirely on the ischial tuberosities, since 
they are on a lower plane than the tip of the coccyx; and this explains why 
transverse pelvic contractions are so much more frequent at this strait than 
are the antero-posterior ones. Although the two lateral notches are so deeply 
marked in the bony pelvis, they are made very superficial by the sacro-sciatic 
ligaments. The anterior notch is known as the arch of the pubis. The col- 
umns of this arch are twisted outward, — this being more marked in the female, — 
and so assist in the passage of the head in labor. By the yielding of the sciatic 
ligaments the oblique diameters may be somewhat increased; this is not 
28 



434 



PHYSIOLOGICAL LABOR. 



important. However, there is an important increase in the antero-posterior 
diameter, resulting from recession of the coccyx, so that although this 
diameter is the shortest one of the inlet, it becomes the longest of the outlet. 

Pelvic Outlet Measurements. — (Compare Pelvimetry, page 175.) (1) The 
antero-posterior diameter is 3I inches (9.5 cm.), and 4} (12 cm.) inches when 
recession of the coccyx occurs. It is measured from the middle of the sub- 
pubic ligament to the tip of the coccyx. (2) The transverse or bis-ischiac 
diameter is 4 inches (11 cm.). It is the distance between the ischial tuber- 
osities. (3) The right and left oblique diameters are 4! inches each (12 cm.). 
They are measured from the center of the right and left greater sacro-sciatic 
ligaments respectively, and because of yielding of these ligaments, are of varying 
dimensions. (4) The circumference of the pelvic outlet is 18 inches (45 cm.). 



c^PHYS/s 




Fig. 522. — The Inferior Surface of the Pelvis, showing the Shape and Diameters 

of the Pelvic Outlet. 



Obstetric Landmarks of the Outlet. — Taking them from before backward, 
we have: (1) The pubic arch, and at its apex the sub-pubic ligament. (2) 
Passing backward, we have the descending ramus of the pubis and ascending 
ramus of the ischium which assist in bounding the obturator foramen and in 
forming the pubic arch. (3) At the junction of the two ischial rami is a thick- 
ened projection, the tuberosity of the ischium. (4) Upon the posterior border 
of the descending ischial ramus, and projecting forward, is a sharp spine, — 
the spine of the ischium, — which when well marked plays an important part 
in the mechanism of labor. (5) The great and small sacro-sciatic ligaments. 
(6) The coccyx. 

Pelvic Planes. — The planes of the pelvis are imaginary levels at different 
portions of the cavity; thus, we have a plane of the inlet, planes of the cavity, 
and a plane of the outlet. By a pelvic plane we mean simply a mathematical 



PELVIC PLANES AND PELVIC AXES. 



435 



surface without depth or thickness. The short, slightly curved, cylindrical 
cavity of the true pelvis, bounded by the bony walls already described, 
varies in shape and size at various levels. For convenience in describing 
these variations and pelvic inclination and angles, we erect imaginary levels 
at different parts of the cavity of the true pelvis. If we accurately fit a piece 
of cardboard into the inlet of the pelvis, the level surface thus produced would 
represent the plane of the pelvic inlet (Fig. 523). In like manner we have a 
plane of the outlet, and planes of the cavity. It is in studying these pelvic 
planes that we observe that the planes of the inlet and outlet are not parallel 
with each other, are not at right angles with the axis of the body, nor are they 
parallel with the horizon. (See Pelvic Angles.) Moreover, it is upon changes 




Fig. 523. — Planes of the Bony Pelvis and Parturient Tract. Plane of the parturient 
inlet; plane of the bony inlet; pubo-sacral plane of the outlet; pubo-coccygeal plane 
of the outlet; plane of the parturient outlet. 



in the shape and size of these pelvic planes that the presence of pelvic deformity 
depends. 

Plane of the Pelvic Inlet (Fig. 523). — As the obstetric conjugate is the avail- 
able antero-posterior space at the inlet, so the obstetric plane of the inlet is 
the space available at the inlet for the passage of the fetal head and body. 
It does not coincide with the anatomical conjugate nor with the anatomical 
inlet. .The plane of the obstetric inlet would be represented by a piece of 
cardboard that so fitted the entrance of the pelvis that its- margins corre- 
sponded to the base of the sacrum, the ilio-pectineal line, and the posterior 
surface of the symphysis along a transverse line § inch (1 cm.) below its upper 
margin. 

Planes of the Pelvic Cavity (Fig. 523). — Hodge constructed a series of planes 



436 



PHYSIOLOGICAL LABOR. 



parallel to the plane of the inlet. Th 3 se planes are obsolete, and we now spe? 
of the plane of greatest pelvic dimensions or middle plane.* It extends fro 
the middle of the posterior surface of the symphysis pubis, over the centr 
points of the internal surfaces of the acetabular cavities, to the upper margi 
of the third piece of the sacrum. This is the largest plane of the pelvis; th 
next in size is that of the inlet, and that of the outlet is the smallest. 

Plane of the Pelvic Outlet (Fig. 523). — As at the inlet, so here we have a. 
anatomical plane of the outlet and an obstetric plane. The latter is somewhat 
above the former and is the plane of greatest bony resistance at the outlet. 
It is also the smallest transverse plane of the entire pelvis, and we also term 
it the plane of least pelvic dimensions. f 

Plane of the Parturient Outlet (Fig. 523 and 524). — At the moment that 



I 



the 

vie 

te: 




Fig. 



524. 



■Planes of the Bony Pelvis and Parturient Tract, and Axes of the Par- 
turient Inlet and of the Bony and Parturient Outlets. 



the presenting part is expelled, the plane of the parturient outlet, or, to be 
more exact, of the vulvo-vaginal ring, is nearly parallel with the long axis of 
the mother's body, and, with the woman in the dorsal posture, looks almost 
directly upward. 

Pelvic Axes. — The axes of the pelvis are imaginary lines passing through 
the centers of the planes of the pelvis, and at right angles to them (Fig. 524). 

* German, Beckenweite. 

t Beckenenge. It touches the posterior surface of the symphysis pubis about \ of an 
inch above its lower margin, just above the ischial tuberosities, and the lower border of 
the sacrum. While this is the smallest transverse plane of the pelvis, it must be remem- 
bered that the yielding character of the sciatic ligaments allows of marked expansion in 
the posterior segment during the expulsion of the fetus. 



PELVIC INCLINATION AND PELVIC ANGLES. 437 

The axis of the inlet is represented by a Vne drawn perpendicular to the center 
pf the plane of the pelvic inlet. This line, prolonged upward, strikes the anterior 
.Ddominal wall near the umbilicus; and projected downward, ends at the 
ourth piece of the sacrum (Fig. 524). The axis of the cavity is represented 
>y a curved line joining the centers of a series of planes extending from the 
Del vie inlet to the outlet, and including these latter planes. It should be stated 
,hat the axis of the true pelvis is an axis of a curved and not a straight cylinder, 
and hence is a curved line, and practically is dependent upon the curves of 
the sacrum and coccyx, and thus of necessity differs according to the indi- 
vidual. The axis of the parturient tract, as will be shown later (Fig. 524), is 
a continuation of the axis of the cavity beyond the bony outlet, by the dis- 
tention of the tissues which go to form the pelvic floor. (See page 458.) The 
axis of the bony outlet is a perpendicular line passing through the center of the 
plane of the outlet, and when there is no recession of the coccyx, this line, 
prolonged upward, strikes the promontory; when the coccyx is pushed back- 
ward, the axis of the outlet strikes the lower border of the first sacral vertebra. 
The axis of the parturient outlet is a perpendicular line passing through the 
center of the plane of the parturient outlet. This line is nearly at right angles 
with the long axis of the mother's body, and is nearly perpendicular. If extended 
backward and downward, it passes some distance below and in front of the 
end of the coccyx. 

Pelvic Inclination and Angles. — In the upright posture of the body the 
plane of the pelvic inlet is inclined obliquely downward. The angle between 
the conjugate and horizon measures 55 to 60 degrees, while the same 
angle at the outlet is 11 degrees (Fig. 524). The inclination exhibits a good 
deal of variability. Not only are there differences in the same measurement 
in different individuals, but the angle is essentially altered by the position 
of the limbs. Thus, it is increased by extreme flexion of the legs and by extreme 
abduction and outward rotation of the thighs. The angle is smaller when 
the thighs are moderately abducted and in slight inward rotation. The size 
of the angle of inclination may be of diagnostic importance, since it calls our 
attention to certain anomalies of the pelvis. As a rule, a change in the direction 
of the plane of the inlet means a corresponding alteration in the axes of the 
uterus and fetus, so that the influence of the inclination up on labor is much less 
than was formerly supposed. On the other hand, the variation of the plane 
of the inlet and axis of the uterus in the different postures of the body is a 
matter of importance to the obstetrician. (1) If the woman lie flat on her 
back with extended limbs, the plane of the inlet sinks backward until it forms 
an angle of 25 degrees, open in front, with the horizon. (2) If she assume 
the knee-chest position, this plane forms with the horizon an angle of 15 or 
20 degrees, open behind. (3) If the pelvis and spinal column are approximated, 
the size of the angle is increased. (4) If the woman lie upon her back across 
the bed in such manner that her thighs hang over the side of the latter, the 
pelvic inlet is expanded. This is the so-called Walcher position, to be con- 
sidered from another point of view. (See Posture in Obstetrics, Part X.) 
In this connection it is only necessary to state that while the angle between 
the inlet plane and horizon is less than in the flat dorsal position, the angle 
between the conjugate and lumbar spine is notably increased. (5) If the 
woman, lying upon her back, flexes her legs at both the hip and knee, 
and at the same time approximates them moderately, forming the lithotomy 
position, the pelvis rotates a little upon its transverse axis so that the angle 
of the flat dorsal position is increased from 25 to 30 degrees or over. (See 



438 



PHYSIOLOGICAL LABOR. 





Fig. 525. — Early Antenatal 
Pelves. (Natural size.) — 
{Author's collection.) 



Part X.) If now the thighs and legs are flexed 
to the utmost so that the thighs are pressed 
tightly against the abdomen, — the exaggerated 
lithotomy position, — the pelvis continues to ro- 
tate upon its transverse axis until the angle 
reaches 60 degrees. There is a corresponding 
diminution in the angle between the spine and 
conjugate. (See Part X.) (7) If with the woman 
in the flat dorsal position the trunk is raised so 
that a reclining posture is assumed, the original 
angle of 25 degrees is reduced to 20 degrees. In 
the squatting or crouching posture the plane of 
the inlet is almost horizontal, and hence hardly 
any angle is present. Variations in the angle 
between the spine and pelvis are made possible 
by the slight mobility of the sacro-iliac joints 
and of the vertebras with each other and with 
the sacrum. As has already been stated, the 
Walcher position causes an expansion of the 
pelvic inlet. The opposite effect of contraction is 
produced by the exaggerated lithotomy posture. 
For a statement of these phenomena and their 
practical application to the mechanism of de- 
livery see Posture in Obstetrics, Part X. If a 
perpendicular falls at the middle of the pelvic 
inlet, it should pass through the coccyx below 
and the umbilicus above, provided that the angle 
between the vertebral column and conjugate is 
normal (125 degrees). If the perpendicular 
passes through the center of the outlet, it would 
pass through the promontory above. The sym- 
physis makes an angle with the inlet of from 90 
to 100 degrees. See also section on Cliseometry, 
page 185. 

Comparison of Different Pelvic Diameters. — 
The most important facts to be remembered 
here are the diameters of inlet and outlet. As 
has been already noted, the shortest diameter of 
the inlet (antero-posterior, 4 -J- in. — 11.25 cm -) 
corresponds when the coccyx has receded with the 
longest diameter of the outlet; and, conversely, 
with the longest diameter at the inlet (transverse, 
5x in. — 13.12 cm.) to the shortest at the outlet 
(4^ in. — 11 cm.). In considering the mechanism 
of labor and the slow progress of the head as it 
gradually descends through the pelvic canal, a 
general rule will be observed concerning the re- 
lationship existing between the fetal head and 
these several diameters of the bony pelvis — 
namely, the long diameter of the fetal head cor- 
responds to the longest diameter of the true 
pelvis. 






FACTORS INFLUENCING DEVELOPMENT OF THE PELVIS. 439 

Factors Influencing Size and Shape of Pelvis. — i. Individual. — Just as with 
any other part of the body, so with the pelvis there are variations with the 
individual. It may consist in thickness of the bones; in their smoothness; 
in the height of the pubic arch; in the curve or length of the sacrum; in the 
depth of the iliac fossae; in the distance between the different landmarks, 
such as the spines, the tuberosities or crests. Many attempts have been made 
to prove a relationship between the height of an individual and the size of 
the pelvis, but without success. 

2. Sex. — Just as in the other bones of the body, those of the pelvis are 
stronger, thicker, and rougher in the male than they are in the female (Fig. 
514). The chief differences concern the cavity, and these are dependent in 
the female on the presence of the uterus. The male pelvis is far more angular 
and markedly cordate than the female, its structure is heavier, and it is less 
delicately curved. The female pelvis is broader and its cavity is rounder 
(Fig. 513). The dimensions of the internal iliac fossa are less in the female 
except the line drawn between the anterior superior iliac spine and the sacro- 
iliac joint; the iliac fossa is shallower in the female; the pelvis of the male 
is, as compared with that of the female, small, deep, steep, and funnel-shaped; 
the tuberosities of the ilium are, in the male, more developed and extend 
farther back; the pubic spines as well as the ischial tuberosities are more 
widely separated in the female. The sacrum presents two curves, concave 
from above downward and from side to side ; this is more marked in the female 
than in the male, the bone being shorter and its direction downward and back- 
ward; in rachitis the lateral concavity becomes straight or even convex; the 
vertical concavity is not an arc of a circle but is bent; this bending point is 
known as the niche, and is found in the third sacral vertebra. The inlet is 
rounder in the female, and all the dimensions are greater, especially the trans- 
verse, which is not only longer but is placed farther forward than in the male 
pelvis. The outlet in the female is much larger on account of the recession 
of the ends of the sacrum and coccyx and the greater distance between the 
tuberosities. The acetabula are relatively farther apart and their surfaces 
look forward rather obliquely; this arrangement is not made to assist the 
function of the hip-joints in walking, and it accounts for the proximity of the 
knees of the female and for the peculiarity of gait. The sciatic notch is shal- 
lower and more open in the female. The pubic arch in the male is more acute, 
or about 70 to 80 degrees; in the female it is more rounded, 80 to 105 degrees; 
the distance between the symphysis and the tuberosities, the anterior pelvic 
wall, is longer than that of the female; in the female the ischio-pubic tubercle 
is turned more outward and the ischio-pubic ramus is concave in the middle. 
In the female there is marked pelvic inclination, while in the male it is slight. 
In the male the sacrum and coccyx are higher and more curved than in the 
female. The ischio-pubic foramen in the female is relatively larger and is more 
oblique externally and interiorly ; the common error that there is a difference in 
its shape in man and woman has been disproved. The ischia are more widely 
separated in the female; all the vertical diameters of the pelvis are greater 
in the male. Just as in other bones of the body, these characteristic differences 
in some pelves are marked, while in others they are slight, so as to make the 
distinction between male and female pelves difficult. 

3. Age. — Infantile and juvenile pelvis. The pelvis is very small in the 
newly born child and is far less developed than the upper part of the body, and 
to this cause is due the greater prominence of the abdomen (Figs. 525 to 530). 
The larger part of the rectum and the bladder are almost wholly in the abdominal 



440 



PHYSIOLOGICAL LABOR. 






cavity, and it is not till puberty that their permanent position is assumed. 
Delivery is naturally made easier from the small size of the pelvis. At the 
time of birth there is a greater development of the false than of the true 
pelvis, the latter being straight and cylindrical in shape. It was not till re- 
cently that the infantile pelvis has been supposed to possess any special 

form. It is in great measure cartilaginous 
with points of ossification. The characteristics 
of the infantile pelvis, as compared with the 
adult, are: (i) The os innominatum is com- 
posed of ilium, ischium, and pubis; the ascend- 
ing and descending rami are entirely cartila- 
ginous; (2) the infant's pelvis is relatively 
more contracted; (3) the iliac bones stand 
more perpendicularly; (4) the sub-pubic angle 
m-- jEO^fj^^K^.' is less; (5) the promontory of the sacrum is 

^| l^^^^^WKr much higher and the sacrum is almost entirely 

straight; (6) the promontory of the sacrum 
forms a much more obtuse angle with the spinal 
column than is found in the adult pelvis (Figs. 
525 to 528). The sacrum has twenty-one cen- 
ters of ossification; each vertebral body, five; 
each vertebral arch, ten; and three on each side 
of the sacrum, making six for the alas. This 
condition persists for some time, and it is not 
According to Litzmann, they unite from below 
three lower bones are ossified; at seven years 
the sacrum is ossified; the three bones of the os innominatum join at puberty; 
at twenty, the pelvis assumes its normal shape. The sacrum in the newly 
born child is more or less wedge-shaped, but does not possess the antero- 
posterior curve of the adult sacrum 
and has little or no curve from side 
to side; the diminution is due to pres- 
sure causing the bodies of the vertebras 
to press forward (Fig. 528). The alas 
are poorly developed; the promontory 
of the sacrum is farther above the 
symphysis pubis; this distance is so 
great that Fehling, in considering the 
genesis of the pelvis, does not use the 
conjugata vera, but what he terms the 
conjugata vera inferior. The transverse 
width is less in the infant and the shape 
is more like a funnel, the pelvic walls 
being more markedly inclined. 

Forces Leading to the Production of 
the Adult Pelvis. — These are important 
because they sometimes lead to deformed pelves. There are two sets of factors 
to be considered. (1) Congenital predisposition or tendency of the pelvis to 
assume a certain form. This is evident when the differences between male 
and female pelves are noted, as both are subjected to the same forces. At 
birth the alas of the first sacral vertebra are only one-half as long as the vertebral 
body itself. In the adult woman the alas are 0.76 as long as the body. In 



Fig. 526. — Antenatal Pelvis of 
about the seventh month. 
(Natural size.) — {Author's col- 
lection.) 

till late that the centers join, 
upward ; at three years the 




Fig. 527. — Antenatal 
the Eighth Month. 

{Author's collection.) 



Pelvis of about 
(Natural size.) — 



FACTORS INFLUENCING DEVELOPMENT OF THE PELVIS. 441 




Fig. 



528. — Fetal Pelvis at the Fortieth Week. 
(Natural size.) — (Author's collection.) 



the adult man they are 0.56 as long, making a difference of twenty per cent. 
The body of the second vertebra is three times as broad as in the child; the 
alae are five times longer in woman and three times in man. (2) Mechanical 
influences. These are very important. They are the normal growth of the 
pelvic bones, the traction 

which ligaments and muscles y^S^^r 

exert upon the developing 
bones, the pressure of the 
superimposed trunk, the 
counter-pressure of the sub- 
jacent skeleton, and the re- 
sistance offered at the sym- 
physis pubis. The excess or 
deficiency of any of these 
forces will modify the shape 
of the pelvis. If the pelvic 
bones do not develop nor- 
mally before birth, a deform- 
ity will result which will be 
a form of the congenitally 
contracted pelvis; of this, the 
Naegele or Roberts pelvis is 
an example. The body-weight 

begins to exert its influence only after the child begins to sit up. Then the 
weight is exerted through the spinal column down through the sacrum. The 
first change consists in the tilting forward of the upper part of the sacrum 
and the pushing outward of the pelvic brim. The sacral promontory is lowered 

and approaches the symphysis 
pubis. Resistance is offered by 
the sacro-iliac ligaments, so that 
the degree of depression of the 
sacrum is limited. The pelvis 
then tends to rotate around a 
certain point backward, but the 
sacro-sciatic ligaments which fas- 
ten the tip of the sacrum to the 
ischii and ischiac spines resist this 
force, so that from the influence 
of all these forces there results 
the curve or bend at about the 
middle of the third sacral verte- 
bra. This concavity distinguishes 
the adult pelvis from that of the 
child (Figs. 518 to 530). If there 
were nothing to oppose this ro- 
tation, the same shaped pelvis 
would be found in both child 
and adult. The lateral concavity is much greater in the infant. The adult 
pelvis is comparatively widened, since the antero-posterior diameter is lessened. 
As long as the child is on its back the body-weight exerts no influence. If 
it were not for the posterior ilio-sacral ligaments, the promontory of the 
sacrum would press against the posterior surface of the symphysis pubis. 




€£ ' S 



Fig. 529. — Bony Pelvis of a Female Child of 
Two Years, (h natural size.) — (Author's col- 
lection.) 



442 



PHYSIOLOGICAL LABOR. 



But the posterior part of the innominate bone extends beyond the spinal 
column. The ilio-sacral ligaments act as a hinge and tend to spread out 
the innominate bones, but this influence is resisted by the heads of the 
femora, which press upward and inward. The innominate bones act like a 
two-armed lever, with the sacrum as a fulcrum and the two forces — body- 
weight and counter-pressure — exerted through the heads of the femora. So 
the iliac bone is bent just in front of the sacrum, thus producing the transverse 
widening of the superior strait. Another force is the resistance offered by 
the symphysis pubis, which counteracts the tendency of the ilia to flare out. 
Certain reported cases illustrate the effects of the various influences noted 




Fig. 530. — Bony Pelvis of a Female Child of Five Years, (f natural size). — {Author's 

collection.) 



above. Gurlt found a hydrocephalic girl who had always lain in bed. She 
was thirty-one years old when she died. Her pelvis was a model of the infantile 
type, though larger in size. The force exerted through the femoral heads 
cannot act without the other forces, so that it never exists alone. Neither 
could resistance offered by the symphysis pubis act alone. Clinically an 
example of body-weight acting alone has never been observed. Theoretically 
it would indicate a split symphysis pubis and undeveloped legs. Freund, 
of Strasburg, experimented with a cadaver, which he suspended by the tips 
of the ilia. He cut apart the symphysis pubis; the ilia spread out while the 
symphysis gaped widely. Litzmann observed a case of split pelvis in which 
there was no union at the symphysis pubis, so only the two forces acted — 
body-weight and counter-pressure of the femora. The resulting pelvis was 



THE MUSCLES OF THE PELVIS. 443 

very wide behind and in front, the sides being almost parallel. The transverse 
width was marked. Hoist saw a case, that of Eva Lank, who was born without 
lower extremities; thus the counter-pressure through the femora was lacking. 
The patient could sit up, consequently the forces — body- weight and resistance 
of symphysis — were exerted. There was a marked flattening of the pelvis 
and a widening of the transverse diameter. The pelvis was flared out beneath 
and the outlet represented the upper end of a funnel — wider below than 
above. It is plain to see that any change from the normal in the action of 
the forces, or in the condition of the parts concerned, will result in a deformity 
of the pelvis which may vary from a slight to an extreme degree. All these 
facts are very important, and especially practical in relation to deformed pelves. 
The inferior races seem to be characterized by an inlet having a lessened trans- 
verse and increased conjugate diameter. Whenever a fair-sized average has 
been made, there has never yet been a people discovered in which the conjugate 
measured more than the transverse diameter. The consensus of opinion seems 
to point to the fact that favorable conditions of nutrition and activity lay 
the corner-stone for a well-formed pelvis. 

Functions. — The functions of the pelvis are to form: (i) A ring by means of 
which the body-weight is transmitted to the lower extremities; (2) an axis which 
permits the movements of the lower extremities upon the trunk; (3) an attach- 
ment and lever for powerful muscles; (4) a cavity to contain the delicate pelvic 
organs; (5) a bony canal for the escape of the fetus from the abdominal cavity 
during parturition; (6) and to assist in the performance, through the pelvic floor, 
of the rectal and vesical functions. 



2. THE SOFT TISSUES OF THE PELVIS. SOFT PARTS. 

Familiarity with the bony pelvis alone is not sufficient for the obstetrician, 
but he must study the pelvis together with the soft tissues, muscles, ligaments, 
and cellular tissue which encroach upon the pelvic space and close in the openings 
of the latter, which is thereby converted into a basin-like body. The blood- 
vessels, the lymphatics, and the nerves also demand attention, and, finally, we 
must go back to our pregnant uterus, already studied under pregnancy, place 
it in position at the pelvic inlet, and carefully consider the pregnant and par- 
turient tract or canal, extending, as it does, from the fundus of the uterus above 
the umbilicus, to the edge of the perineum, which latter in the second stage 
of labor may be distended five inches below the coccyx. 

1. Muscles. — By the presence of the muscles of the pelvis, especially the 
ilio-psoas (Fig. 531), the transverse diameter of the inlet is made smaller than 
the oblique. This is one cause for the prevalence of the oblique position of 
the fetal head in cephalic presentations. The function of the musculature of 
the pelvic canal, ilio-psoas, obturator, levator, and other muscles, is mechanical 
during parturition. They protect the bony pelvis and guide the presenting 
fetal part in a line which favors its expulsion; they also serve as cushions on 
which the fetus may rest and avoid injury from pressure. The muscles 
of the pelvic floor, especially the levator ani and coccygeus, during parturition 
are, to an extent, passive. Their yielding is out and back, and they are often 
lacerated from their resistance to the presenting part. However, the direction 
of the resistance turns the head out and up under the symphysis. The functions 
of these latter muscles are to give support to the viscera of the pelvis, complete 
the lower end of the parturient canal, and to direct the presenting part to the 
orifice of the vulva. 



444 



PHYSIOLOGICAL LABOR. 



Psoas Magnus (Fig. 531). — The psoas magnus is long and fusiform and is 
situated on the side of the lumbar region of the spine and the pelvic brim. It 
takes its origin from the bodies, transverse processes, and intervertebral sub- 
stances of the last dorsal and all the lumbar vertebras, and is inserted into the 



RIGHT CRUS OF DIAPHRAGM 



INTERTRANSVERSALIS M 



QUADRATUS LUMBORUM M 



LEFT CRUS OF DIAPHRAGM 



PSOAS PARVUS M 



PSOAS MAGNUS M 



ORIGINS OF PSOAS MAGNUS M 
FROM THE TRANSVERSE 
PROCESSES OF THE 
LUMBAR VERTEBR/E 



PSOAS MAGNUS M 
CREST OF ILIUM 



PYRIFORMIS M 




GREAT TROCHANTER OF FEMUR 

LESSER TROCHANTER OF FEMUR 

OBTURATOR EXTERNUS M 



OBTURATOR MEMBRANE 



QUADRATUS FEMORIS M 



PECTINEO-FEMORAL BAND OF THE CAPSULAB 
LIGAMENT OF THE HIP-JOINT 



Fig. 531. — The Pelvic Inlet Seen from Above, showing the Psoas and Iliacus 

Muscles. — (Deaver.) 



lesser trochanter of the femur by a common tendon with the iliacus. Its action 
is to flex and rotate the femur outward, also to flex the trunk and pelvis on 
the thigh. Obstetrically it acts as a "bumper" or protection between the fetus 
and the margin of the pelvic inlet; it diminishes the transverse diameter of 
the inlet, so that in the recent state the oblique diameters become the longest, 



THE MUSCLES OF THE PELVIS. 



445 



and this partly explains the oblique position of the head in cephalic presenta- 
tions. 

Psoas Parvus (Fig. 531). — The psoas parvus is long and slender and is 
situated in front of the psoas magnus. It takes its origin from the bodies of the 
last dorsal and first lumbar vertebrae and the intervertebral substance, and 
is inserted into the ilio-pectineal eminence and the iliac fascia. Its action is 
to make tense the iliac fascia. 

Iliacus (Fig. 531). — The iliacus is a flat muscle filling up the entire internal 
iliac fossa. It takes its origin from the iliac fossa, the inner surface of the 
iliac crest, ilio-lumbar ligament, base of the sacrum, anterior spinous processes 
of the ilium as well as the notch included between them, and from the capsule 
of the hip-joint. It is inserted into the external surface of the tendon of the 
psoas magnus. Its action is the same as that of the psoas magnus. The psoas 



PUBIC BONE 



SPHINCTER VESIC/E M 
AND NECK OF BLADD 



URATOR FASCIA 



URATOR CANAL 



LEVATOR ANI M 

FIBROU8 RAPHE 

CR RECTO- 
COCCYGEAL LIQ 




;\H^r 



Fig. 532. — Muscles of the Female Pelvic Floor — Superior View. — (Deaver.) 



and iliacus flex the thigh upon the pelvis while they rotate the femur outward : 
these functions are performed when they act from above. From below, with the 
femur fixed, the lumbar part of the spine and the pelvis are bent forward by the 
action of the muscles of both sides. By them also the erect position is main- 
tained, since they support the spine and pelvis upon the femur, and help to 
raise the trunk when the body is recumbent. 

Levator Ani (Fig. 532) . — This muscle takes its origin from the body and ramus 
of the pubis posteriorly, the pelvic fascia, and the spine of the ischium, and is 
inserted into the tendinous center of the perineum, the sides of the rectum and 
vagina, the apex of the coccyx, and a fibrous raphe* extending from the coccyx 
to the anus. There has been much contradictory discussion concerning the 
complicated form and functions of the levator ani muscle. The shape of the 
muscle is that of a horseshoe. It acts like a sling which is anteriorly attached 
to the pubes, and, passing backward in a horizontal plane, encircles the rectum 
and vagina (Dickinson). Luschka describes it as the diaphragm of the pelvis, 



446 PHYSIOLOGICAL LABOR. 

but states that in many non-pregnant women it is almost membranous; we 
must remember, however, that there is always a hypertrophied condition of 
the muscle present during pregnancy. Its arrangement consists of flat bundles 
of muscle-fibers loosely connected, between which here and there are open- 
ings filled up with connective tissue and fat. The good use to which such a 
structure lends itself in the great distention of delivery can easily be seen. 
The depth of the levator in woman is less than that in man, corresponding 
with her shallower pelvis; while, as has already been shown, the horizontal 
measurements are greater. According to Henle, the longitudinal muscle-fibers 
of the lateral vaginal walls are intertwined with the fibers of the levator ani — 
an arrangement analogous to that about the rectum. The division of the 
levator which reaches to the front of the rectum is a verv narrow band. In 




Fig. 533. — The Parturient Pelvic Inlet Seen from above, showing the Narrowing 
of the Transverse Diameter Caused by the Psoas Muscles. 

shape it resembles a bow, with its most inferior extremity about one-half 
inch above the anus. This band arises at the outer side of the pubic origin, 
crossing over the larger bundle in its course. This part of the muscle in women 
is very small and is "collected together in the recto- vaginal septum." This 
fact can be proved, as a rule, by palpation. The connection between the levator 
and the walls of the rectum is very intimate, although none of the muscle- 
fibers end in the walls. There is the same intimate intermingling with the 
longitudinal muscle-fibers as was noted about the vagina. The functions of 
this muscle are numerous and important: (1) During the internal rotation 
of the second stage of labor the levator, together with the coccygeus, internal ob- 
turator, and trans versus perinei, are the chief causes in determining the anterior 
rotation of the lowest portion of the presenting part. (2) The most character- 



THE MUSCLES OF THE PELVIS. 447 

istic action of the levator is to draw forward toward the symphysis the anus 
and perineal body, thus directing the head or presenting part out under the 
symphysis, and relieving the strain on the perineum. (3) In the female the 
pubo-coccygeal part of the levator ani serves the purpose of a sphincter muscle 
of the vagina, and perhaps of the urethra after the collapse of the vagina. (4) 
It antagonizes the diaphragm in its action on the pelvic contents, as it rises 
and falls with it in deep respiration. When the abdominal muscles are acting 
energetically, this muscle yields, enabling the pelvis to endure a greater strain 
than if it were more resistant. When the tension is removed, the muscle restores 
the perineum to its original condition. (5) It assists in the formation of the 
pelvic floor and supports the lower end of the rectum, vagina, and bladder. 
According to Studdiford,* the levator ani does not form a sling, but is more 
like a narrow V with sides slightly convex toward the median line. A band 
of involuntary muscular fibers seated between the rectum and vagina serves 
to connect the two portions of the levator. This is the muscular band which 
may be felt behind the posterior vaginal wall. By its action the two segments 
of the levator ani are approximated, so that the vagina is forced upward behind 
the pubis while the rectum and coccyx, and probably the external sphincters, 
are drawn forward. Studdiford attaches great importance to this band of 
smooth muscle, and believes that by its automatic action the levator is enabled 
to furnish continuous support to the pelvic viscera. 

Obturator Interims (Fig. 532). — It takes its origin from the inner surface 
of the obturator membrane and the posterior osseous edge of the obturator 
foramen, as far as the ilio-pectineal line above and the sacro-sciatic notch behind ; 
its fibers converge and form a tendon which passes through the small sacro- 
sciatic foramen, and then is directed downward and backward to be inserted 
into the digital cavity of the great trochanter. Its action is to rotate the thigh 
outward; to assist in increasing the resistance of the posterior segment of 
the pelvic floor; to act as a bumper and protection to the fetus. Owing 
to its thinness, this muscle does not materially affect the dimensions of the 
pelvic cavity. 

Pyriformis (Fig. 532). — The pyriformis arises by three digit at ions from the 
front of the second, third, and fourth sacral segments, from the border of the 
great sacro-sciatic foramen and the great sacro-sciatic ligament, and is inserted 
into the upper border of the great trochanter after having passed through 
the great sacro-sciatic foramen. Its action is to rotate the thigh externally; 
it helps to form the posterior and outer wall of the pelvic cavity; in fact, its 
action is the same as that of the obturator internus. 

Coccygens (Fig. 532). — This is a small, triangular muscle, by many included 
in the description of the levator ani. It is situated in front of the small sciatic 
ligament, between the levator ani and the pyramidalis. This muscle takes its 
origin from the spine of the ischium and radiates its fibers in the form of a 
fan and is inserted from the tip of the coccyx to the lateral surface of the two 
lower sacral vertebrae, filling up the open space behind the levator. Its action 
is to support the coccyx and to close the pelvic outlet behind. The pelvic 
surface helps to support the rectum, while externally it is closely connected 
with the lesser sacro-sciatic ligament. This muscle assists in restoring the 
coccyx to its original position after the strain of parturition or defecation is 
passed. In caudate animals it is strongly developed and causes lateral move- 
ments of the tail. 

Bulbo-cavemosus (Fig. 532). — This muscle, which is sometimes misnamed 
* New York Medical Journal," April 12, 1902. 



448 PHYSIOLOGICAL LABOR. 

the sphincter vaginae or constrictor cunni, is analogous to the lateral half of 
the male accelerator urinas muscle. Analogous to the role of the coccygeus, 
which completes the muscular diaphragm back of the levator, is that of the 
bulbo-cavernosus, which aids in closing the space between the ends of the 
horseshoe, although it is a thin, weak muscle. Each bundle takes its origin 
from the fascia of the perineum about half-way between the anal sphincter 
and the ischia, only a small band being connected with the sphincter (Luschka). 
Anteriorly the ends as they converge divide into three bands. One part goes 
to the inferior surface of the corpus cavernosum of the clitoris, another passes 
to the posterior surface of the bulb, and the third mingles with the mucous mem- 
brane between the clitoris and the orifice of the urethra (Henle). The action 
of this muscle is chiefly seen in its function of compressing the veins of the 
clitoris, and thus increasing the turgidity of the erectile tissue and so main- 
taining as well as creating erection of the clitoris. It is not a sphincter, although 
by means of its pressure inward on the turgid bulbs the vestibule of the vagina 
may be made smaller. Unless hypertrophied it cannot be discovered by pal- 
pation. 

Transversus Perinei, or Ischio-bulbosus (Fig. 532). — This muscle arises from 
the ascending ischial ramus and is inserted into the base of the perineal body, 
the fibers of the two muscles intermingling at this point. Its action is to make 
the central tendon of the perineum tense, so that the other muscles attached 
in that vicinity may have a fixed point from which to act ; it also antagonizes 
the action of the levator ani. In deep perineal laceration the two muscles 
tend to produce gaping of the wound, and interfere with union. 

External Sphincter Ani. — From each side of the ano-coccygeal ligament, 
just beneath the superficial fascia, thin sheets of striated muscle-fibers arise, 
and passing forward blend with the other muscle-fibers ending in the perineal 
body, thus surrounding the anus elliptically. Its fibers are interwoven with 
those of the bulbo-cavernosus muscle. Its action is to contract the skin about 
the anus; to assist the levator ani in supporting the opening during the strain 
of defecation; and to close the anus. 

2. Ligaments (Fig. 522). — The sacro-sciatic ligaments number four: two 
posterior and two anterior. The great sacro-sciatic ligament arises from the 
posterior inferior iliac spine and the posterior aspects and borders of the sacrum 
and coccyx, and is inserted on the internal border of the tuberosity and the 
ascending ischial ramus. The small sacro-sciatic ligament arises from the 
borders of the sacrum and coccyx, and is inserted into the ischial spine. The 
sacro-sciatic ligaments close the wall of the pelvis and offer protection to 
and direct the presenting part. The obturator membrane closes the foramen 
and acts as a cushion for protection of the presenting part. Besides the four 
sacro-sciatic ligaments there are the anterior, posterior, and lateral sacro- 
coccygeal ligaments, which connect the sacrum and the coccyx; the anterior, 
posterior, and superior pubic ligaments, connecting the two pubic bones. 
These ligaments help to modify the shape of the pelvis and the direction of 
its axis, as well as to act as buffers for the presenting part. 

3. The Pelvic Cellular Tissue. — It is only by the additional support afforded 
by layers of fascia or by a mixture of fibrous tissue that even the strongest 
muscle can resist strain that is prolonged. The pelvic cavity may be considered 
to be divided into two spaces — peritoneal and subperitoneal — by an imaginary 
plane which passes from the central point of the inner surface of the pubis to 
that point where the third and fourth sacral bones unite. With the exception 
of a part of Douglas's pouch the whole pelvic peritoneum should lie above 



LIGAMENTS, CELLULAR TISSUE, VESSELS AND NERVES. 449 

this plane. It is beneath the plane in the intervals between the pelvic viscera 
where are the blood-vessels, lymphatics, and nerves, as well as fibrous and mus- 
cular tissue, and fibro-elastic elements, all of which comprise the cellular tissue 
of the pelvis. The proportions of these different elements vary according 
to the function to be performed. The function depends to a certain extent 
upon the situation of the tissue. When investing blood-vessels, it assists in 
the erectile functions of the venous system of the pelvis. When used as an 
attachment for organs, it becomes more ligamentous in character and helps 
to preserve the mutual relations of the organs which it helps to connect as 
well as their normal position. Some parts of it act as lines of traction upon 
different parts of the uterus. Parts of it keep in contact the vaginal walls, 
since that organ is not only drawn backward but also toward the side of the 
pelvis. This tissue also forms part of the uterine system. During pregnancy 
this tissue is greatly hypertrophied in order to fill the space that is left vacant 
when the uterus with its broad ligaments ascends. After delivery the excess 
of tissue is gradually absorbed, and the uterus and its ligaments by degrees 
return to their normal position. This tissue surrounds the cervix, and from 
this point reaches out between the layers of the broad ligaments to the wall 
of the pelvis. Much work has been done of late years on the arrangement 
of this pelvic cellular tissue, by various methods: (i) By frozen sections and 
pelves hardened in spirit; (2) by injections beneath the peritoneum in various 
places and later tracing the ramifications; (3) by water injections; (4) by 
plaster-of-Paris injections. The recto-vaginal process extends between these 
two organs down to the pelvic floor, and permits of the changing degrees of 
distensibility of these tubes. The vagino-vesical process is found between 
the superior part of the anterior wall of the vagina and the posterior vesical 
surface. There is no such deposit of connective tissue between these organs 
in the lower two-thirds of the vagina. Since the amount of tissue in this process 
is so small the pelvic peritoneum and the upper part of the anterior wall of 
the vagina come very close together when the bladder is empty — a point of 
value for the surgeon. The rectum and the sacrum are separated by a little 
connective tissue. 

4. Blood-vessels and Lymphatics. — The blood-vessels of the pelvic floor 
consist of the branches directly or indirectly derived from the anterior divi- 
sion of the internal iliac, together with the veins which accompany them; 
besides these there are numerous plexuses which are in close proximity to 
the vesico- vaginal walls. The branches of the inferior pudic, the smaller of 
the terminal branches of the anterior trunk of the internal iliac, are: inferior 
hemorrhoidal, superficial perineal, transverse perineal, artery of the bulb, 
artery of the corpus cavernosum, and dorsal artery of the clitoris. The sciatic 
with its branches supplies the muscles on the back of the pelvis. Besides 
these the inferior vesical and vaginal arteries with small branches from the 
external pudic form a part of the pelvic blood-supply. The inferior hemor- 
rhoidal and the superficial perineal arteries supply particularly the musculature 
of the pelvic floor. The superficial perineal artery passes through the super- 
ficial fascia to the superficial perineal space and supplies the neighboring struc- 
tures, giving off the transverse perineal branch. The continuation of the internal 
pudic artery lies deeper, being between the two layers of the triangular ligament. 
Here the arteries of the vestibular bulbs and of the crura of the clitoris branch 
off. The internal pudic artery ends, having penetrated the anterior layer 
of the triangular ligament, as the dorsal artery of the clitoris, from which small 
branches reach the corpus cavernosum, the glans, and the prepuce. The ovarian 
29 



450 PHYSIOLOGICAL LABOR. 

arteries from the abdominal aorta pass to either side of the pelvis, and, running 
between the laminae of the broad ligament, supply the ovaries and tubes, one 
branch passing to the fundus, another traversing the uterus and there anasto- 
mosing with a branch of the uterine artery. The latter artery passes down 
from the anterior trunk of the internal iliac to the uterine neck. Ascending 
the sides of the uterus one branch meets the ovarian, and one, the circular 
artery of the cervix. Incision of this artery or rupture causes marked 
hemorrhage. The most important veins are the tributaries of the pudic 
vein and those having an independent course forming a part of the ves- 
icovaginal and hemorrhoidal plexuses. This venous supply is abundant. 
The lymphatics owe their chief importance to their relation to septic ab- 
sorption. The uterine lymph-spaces lie between bundles of connective tissue 
and are covered with endothelial cells. These finally lead to the thoracic duct. 
The glands of most importance are the sacral, lumbar, hypogastric, obturator, 
inguinal, and uterine. 

5. Nerves (Fig. 157). — These are derived principally from the sympathetic 
system. From the uterine plexus are given off two hypogastric plexuses from 
which twigs pass to the uterus and ovaries. To the perineum are distributed 
branches of the internal pudic nerve and the inferior pudendal branch of the 
small sciatic. The pudic, inferior hemorrhoidal, superficial perineal, deep 
perineal, muscular filaments of the pudic, and dorsal nerve of the clitoris are 
described as the nerves of the female perineum. 

3. THE PARTURIENT CANAL. 

Definition. — This term is applied to the cavity of the uterus, cervix, vagina, 
and vulva, regarded as a single structure. Many obstetricians, however, restrict 
the term to the parts which lie below the internal os, and define the birth 
canal as the dilated passage or route by which the fetus must reach the external 
world through the action of the expulsive forces exerted in the abdominal 
region. The present conception of the birth canal as embracing the entire 
genital tract is regarded as the most expedient. The term parturient canal, 
however, does not apply to the genital passages in a state of quiescence. It 
is present then, of course, in a potential sense only. The actual canal exists 
only during labor, when the onward progress of the fetus, together with the 
active dilatation and resistance offered to its passage, transform the distensible 
structures into an anatomo-physiological entity which has its own individuality 
and which demands a careful description. A knowledge of the bony pelvis, 
the soft parts, and the changes which the uterus and other genitals undergo 
during pregnancy is requisite before proceeding to the study of the parturient 
canal. 

Formation. — At the end of pregnancy the uterine cavity is distended by 
the mature ovum which is closely united to the external membranes, decidua, 
and uterine wall (Fig. 135): The internal os.is tightly closed and the cervical 
canal as well (Fig. 136). In the primigravida the external os is likewise closed 
and but slightly patulous in the multigravida. (See page 136.) A similar 
condition of stenosis is present in the vagina and vulva. The potential cavity 
now consists of two sections, the upper of which is represented by the uterine 
cavity, while the lower comprises all the parts below the latter. The ripper 
section, already distended to the utmost, will dilate no more, but tends, on 
the contrary, to contract upon and expel its contents, thereafter , resuming 
its original and natural state of closure. The lower section, on the other hand, 



THE PARTURIENT CANAL. 



451 



heretofore in a state of natural occlusion, must now be subjected to the utmost 
degree of distention. The transformation of the potential into the actual 
cavity, then, affects only those parts which have no active function of con- 
traction. The precise line of demarcation between the two segments of the 
uterus — i. e., the functionally active and the functionally passive — is a matter 
of dispute. It was formerly assumed that the internal os marked the boundary 
between the segments, for in the state of quiescence this structure appears 




Fig. 534. — Frozen Section after Sudden Death from Cerebral Abscess during 
the First Stage of Labor. Age of patient thirty-seven years; 7-para; fundus uteri 
3 inches above the umbilicus; internal os dilated to admit two fingers. The section 
shows the interior of the left half of the uterine cavity with placenta and membranes 
in situ. Note that the internal os has not been drawn up into the walls of the uterus; 
the beginning formation of the contraction ring just above the plane of the pelvic 
inlet, and that the rectum is impacted with feces. — {William C. Lush's case.) 



to indicate that the first act of labor must be to overcome the resistance at 
this point. 

Contraction Ring. — According to modern teaching, the very first step 
in the establishment of the parturient canal is the formation of the 
so-called contraction ring, in the uterine wall at a point somewhat higher 
up than the anatomical internal os, which latter, it is claimed, is of no 
assistance whatever in the parturient canal (Figs. 534, 537). This contrac- 



452 



PHYSIOLOGICAL LABOR. 



tion ring, which often goes by the name of Bandl's ring, is seated at a point 
in the uterus opposite a large coronary vein, and at which the serous coat of 
the organ adheres intimately to the subjacent muscle (Figs. 536, 537, and 538). 
It constitutes a wall-like ridge along the uterine cavity and divides the latter 
into two segments, known as the upper and lower uterine segments, which 
are peculiar to the parturient canal, having no existence save during the act 
of labor (Fig. 537). The transitory existence of this ring gives it a problematic 
character. We do not know whether it is always the same in different uteri 
or even in the same uterus at different periods. That it undoubtedly exists 




Fig. 535.— Frozen Section of the Uterus and Fetus from a Primipara, Aged Twenty- 
four, who Died Suddenly from an Unknown Cause Two Hours after Admis- 
sion to the Emergency Hospital. Labor had continued twenty-four hours, and 
at time of death secondary inertia was present. The cadaver was frozen within 
twenty-four hours, and the section made forty-eight hours from death. The caput 
succedaneum is distending the parturient outlet, and the head lies upon the pelvic 
floor in the left occipitoanterior position before anterior rotation of the occiput. 
(Compare Figs. 536 and 537.)— (Dr. W. E. Studdiford's case at the Emergency Hospital.) 

has been shown by frozen sections of women dying in labor (Figs. 538 and 539} 
and by digital exploration during labor, while its existence is often implied 
by various phenomena during parturition, such as special types of dystocia 
and peculiar forms of rupture of the uterus. It is by no means certain that 
those uterine fibers which lie between Bandl's ring and the site of the internal 
os do not contract to some extent. Another dubious point refers to the possi- 
bility of independent contraction of the ring, most obstetricians holding that 
this contraction is necessarily a part of the general action of the uterine muscle. 
The consensus of opinion is that the ring is non-existent save during a labor 



J 



THE PARTURIENT CANAL. 



453 



pain. Veit,* who has recently written at length upon the contraction ring, 
claims that with the beginning of dilatation that part of the uterus which is 
to form the future inferior uterine segment is distinctly thinner than the upper 
or functionally active segment. 

Cervical Dilatation. — The labor pains acting upon the amniotic fluid 
which invests the fetus make uniform pressure within the uterine cavity. 
The potential cavity of the cervix is naturally the locality which must give 
way by a process of dilatation, and the amniotic sac with its fluid is forced 
into this cavity in a wedge shape. With the inception of the pains the mem- 
branes begin to separate from the contractile portion of the uterus, remaining 
adherent, however, below the site of the actual or hypothetical contraction 
ring. This separation varies in kind. Usually it occurs between the layers 



LOWER BORDER 
OF PERITONEUM 



CONTRACTION 

RING 




UML 



Fig. 536. — Outline of Fig. 535 with Explanatory Titles. 



of the decidua, although in some cases the detachment occurs between the 
chorion and amnion. Next in sequence to the formation of the contraction 
ring and dilatation of the cervix there occur certain changes throughout the 
uterine walls. 

Uterine Walls. — As the cavity of the uterus begins to discharge its 
contents the muscular bundles which constitute the uterine wall undergo a 
process of readjustment. Lamellae of muscle which were formerly superimposed 
in strata now come to lie side by side, with resulting thinning of the uterine 
wall. (Compare Figs. 537 and 538.) At the same time there ensue changes 
in the position of the uterus. The latter begins to move backward and at 
the same time to ascend. During the formation of the birth canal the fundus 
* " Monatschrift f. Geburts. u. Gynakol.," Feb., 1900. 



454 



PHYSIOLOGICAL LABOR. 



gradually ascends until it reaches the costal arches, and synchronously with 
this ascent there is also a slight lateral deviation, usually to the side which 
is opposite to the fetal back. As the uterus rises the contraction ring also 
ascends, and when the birth canal is fully formed the ring should be nearly 
midway between the symphysis and navel (Figs. 534 and 536). This traction 
which affects the upper segment and ring must affect the lower segment 
as well; but as the cervix is held fast below, the lower segment must undergo 
a process of stretching. In the primipara the dilatation of the cervix is a much 
more laborious process than in the multipara, for in the latter much less resist- 
ance is encountered owing to the semi-patulous condition of the external os 
and cervical canal. In other words, the muciparous uterus has to oppose 




Fig. 537. — Frozen Section seen in Fig. 535 with Fetus Removed. Note the contrac- 
tion ring; the unruptured membranes; the shape of the parturient tract, including 
uterus and vagina, and the thinness of the lower and the thickness of the upper uterine 
segments. — {Dr. W. E. Studdiford' s case at the Emergency Hospital) 



chiefly the resistance of the internal os. The lax walls of the vagina, abun- 
dantly moistened by the natural secretions, offer but little resistance to the 
fetal head, by which they are readily separated. In primiparae, however, 
the degree of resistance is considerable. The maximum of opposition is found 
at the ostium vaginae, where the distensibility is much less marked, and where, 
moreover, additional resistance proceeds from the active contractions of the 
levator ani muscle. This resistance is gradually overcome by the advancing 
head, and is always much greater in the primipara, causing prolongation of 
the period of expulsion. 

The completed canal or tract through which the process of expulsion takes 
place is irregular, with a curved axis (Fig. 523); the successive cross-sections 



THE PARTURIENT CANAL. 455 

vary in shape in a definite manner, and the walls of the canal vary in rigidity 
at the various segments. This canal, when completed under the combined 
influence of the active uterine contractions and the passive dilatation of the 
parts below the contraction ring, may be divided into three portions: viz., 
(i) suprapelvic, (2) pelvic, and (3) infrapelvic. 

Suprapelvic Portion. — The suprapelvic portion consists of the uterus, and 
requires no description in this connection. (See Part 11.) In view of the 
active and passive functions respectively of the abdominal walls and false 
pelvis, some authorities describe these structures as portions of the birth tract, 
but these I omit. It is at times a hollow, more or less cylindrical organ, and 
although it is a part of the parturient canal mechanically considered, it is more 
especially the force which urges the fetus on than a part of the passageway 
through which it travels. 

Pelvic Portion. — The pelvic portion contains the cervico-vaginal portion 
of the birth tract. During the elongation of the uterus and dilatation of the 
os the cervix lies within the pelvic excavation. The custom of describing the 
bony pelvis as a portion of the birth tract does not appear to me to be advisable 
(Fig. 523)- 

Infrapelvic Portion.— This consists of the distended and thinned sacral 
segment of the pelvic floor (Fig. 523). When the utero-vaginal portion of 
the birth tract has been formed by the act of labor, another step is required 
for the completion of this structure, viz., elongation of the pelvic floor. When 
the head of the child is upon the pelvic floor, the latter must necessarily go 
through some form of violent alteration in shape before the passage of the fetus. 
The capacity of the floor for distention is limited. But these changes in the 
pelvic floor are not wholly effected in the single act of expulsion. A study 
of this structure in frozen sections and otherwise shows that there are natural 
differences between its relation in the non-pregnant and that in the pregnant at 
term. While in the former the pelvic floor projects but slightly below a line 
which passes from the tip of the coccyx to the lower border of the symphysis, 
in the woman at term the perineum is already relaxed as well as thickened 
by oedema, so that it bulges considerably beneath the natural level. The 
ascent of the uterus, already described in connection with the formation of 
the utero-vaginal portion of the birth tract, tends to draw upward the parts 
anterior to the vagina; so that the fetal head does not force them below the 
symphysis (Fig. 580). The distensible portion of the pelvic floor is therefore 
the portion posterior to the vagina known as the sacral segment of the pelvic 
floor. This segment appears at first sight to be thrust forward, and at the 
same time elongated by the advancing head. But a study of lead-tape tracings 
upon the pelvic floor during labor shows that the soft parts are really forced 
backward, and at the same time excessively thinned. The anus is moved 
backward. The pelvic floor projects but one inch in the non-pregnant. At 
term its projection is 2f inches (7 cm.), and during labor an additional inch 
is added. The normal perineum is ij inches (3.17 cm.) long, while during 
complete dilatation it measures 2 J inches (6.35 cm.). This increased projection 
of the floor with its backward displacement and elongation appears to be due 
entirely to the thinning of the sacral segment in response to the distention 
of the fetal head. While the perineum is almost three inches in thickness 
at term, it is but an eighth of an inch thick at the moment of expulsion. 

Parturient Canal as a Whole. — This structure consists of an actively con- 
tracting uterus in the shape and position which it assumes in virtue of its ascen- 
in the abdominal cavity; and the passive portions, namely, vaginal and vulval, 






456 



PHYSIOLOGICAL LABOR. 




Fig. 538. — Uterus and Vagina from a Case of Sudden Death from Eclampsia near 
the End of the Second Stage of Labor. Note the retraction ring; the external 
os, the thickness of the uterine walls of the upper and lower uterine segments, and 
the region of the internal os. — {Author's case at the Emergency Hospital.) 



THE PARTURIENT CANAL. 



457 



which complete the canal and form a pronounced curve with a short anterior 
and long posterior aspect (Fig. 523). The former is equivalent to the anterior 




Fig. 539. — Outline of Fig. 538 with Explanatory Titles. 



uterine wall and the posterior surface of the symphysis plus the soft parts 
which lie in front of the pubic bone, and the latter to the concavity of the pos- 



458 PHYSIOLOGICAL LABOR. 

terior uterine wall, the sacrum and coccyx plus the stretched and elongated 
perineum. If each of these surfaces, the shorter anterior convex and the long 
posterior concave, is divided into a given number of equivalent segments, 
and the points which correspond on each surface are cut through by planes, 
an imaginary line passing through the center of each of these planes will describe 
a certain curve which is not the arc of a circle (Fig. 524). This curve represents 
the axis of the birth canal, and must be described or followed by the center 
of any solid mass which is forced through this passage. Numerous attempts 
have been made to represent the various angles of inclination, axes, and curves 
of the birth tract, but a total lack of agreement exists in the views of obstetri- 
cians on this geometrical problem. In 1828 Cams attempted to show that 
the parturient axis should be regarded, for practical purposes, as the arc of 
a circle, the center of which was represented by the center of the posterior 
surface of the symphysis. In this sense Carus's curve was understood by 
Meigs, Tarnier, and others. But Carus states himself that the actual curve 
is not the arc of a circle, but a so-called curve of the higher order, such as form 
the subject-matter of Cartesian or analytic geometry. He intimates that he 
has determined the formula for such a curve, and refers the reader to an in- 
accessible work upon the skeleton. The arc of a circle appears to represent 
the curve to the parturient canal in the drawings attributed to Krause, and 
Moreau and Jacquemier, as cited in Varnier's analytic study of labor.* In 
addition to difference of opinion as to the parturient curve, authors do not agree 
as to the axis of the parturient uterus and superior strait. While many speak 
of these axes as one and the same, Faraboeuf and Varnier regard them as dis- 
tinct. With this last view I am in accord. 



II. THE FETUS. 

Although it is now well known that during parturition the child is entirely 
inactive, and so offers itself as a passive factor only, nevertheless certain parts 
of the child do indirectly exert a modifying influence on child-birth. Obstetri- 
cally considered, the fetus is made up of a head and a trunk, and constant 
reference is made to the vertex, occiput, bregma, brow, and chin of the head, 
and to the shoulders and pelvis or breech of the trunk (Figs. 540 to 557). While 
the bulkiest part of the fetus in its normal attitude or posture is the trunk 
(see Attitude), still the head is least compressible, and so, obstetrically, is 
larger than the trunk during the passage of the fetus through the pelvis, because 
it offers the principal resistance. The head is much larger in proportion to 
the trunk in the fetus than in the adult (Fig. 552). 

The Fetal Head. — Because it is least compressible, and so the most important 
factor in the mechanism of labor, the head is the most important part of the 
fetus. Still, it is yielding to a certain degree, as is shown by the change in 
shape, which varies according to the diameters in which the compressing force 
is applied. (See Moulding.) The fetal brain will endure with impunity much 
compression and change in shape and volume, particularly as regards the hemi- 
spheres. The solidity of the bones at the base of the skull protects the ganglia 
in that region. At term the shape of the fetal head is oval; the two parts 
of the frontal bone are not closely united at birth and the incompressible base 
and the compressible vault can be most clearly compared by making a section 

*" Obst6trique Journaliere," 1900. 



THE FETAL HEAD. 



459 






through the skull parallel with the coronal suture just a little posterior to it 
and passing through the parietal eminences and the mastoid processes. The 
bones of the base are solid and compactly ankylosed; the compressible vault 
consists of flexible, semi-cartilaginous laminae, which aie, except the frontal 
bone, united to the base and to each other by membrane alone. The face 
of the child as compared with that of the adult is remarkably small in propor- 
tion to the cranium. The lower jaw particularly differs from that of the adult; 
there are no teeth, and, the ramus being short and oblique, the lower maxilla 
approaches closely to the upper, bringing the angle of the chin very near to the 
center of the forehead, and rendering the distance from the tip of the chin 
to the root of the nose not more than i-J to i^ inches (3.17 to 3.75 cm.). 



,3* B 



0^ A " 



.-» 




POST£XO-lA T£ffAL 
/ro/vrA/V£Z.L£ 

Fig. 540. — Diameters and Landmarks of the Fetal Skull. Lateral Surface. 



Regions and Protuberances. — The occiput is the region of the fetal 
head behind the posterior fontanelle including and surrounding the external 
occipital protuberances (Fig. 540). The vertex is the region between the an- 
terior and posterior fontanelles and is bounded laterally by the parietal pro- 
tuberances. The bregma is the anterior fontanelle. The sinciput, or brow 
is the region immediately in front of the bregma and including the anterior 
portions of the two primitive halves of the frontal bones (Fig. 540). We find 
five protuberances upon the fetal head which are important as obstetric bony 
landmarks. The occipital protuberance is situated at about the middle of the 
occipital bone and an inch posterior to the posterior fontanelle (Fig. 542). 
The parietal protuberances are situated at the center of the parietal bones (Fig. 



460 



PHYSIOLOGICAL LABOR. 



540). The frontal protuberances are situated at the center of the frontal bones 

(Fig. 543)- 

Bones. — The bones composing the vault of the head are the two frontal, 
two temporal, two parietal, and the occipital. The squamous portions of the 
fetal skull form such small parts of this vault that they scarcely need be brought 
up for consideration (Fig. 540). If observed from the standpoint of obstetrics, 
the base may be seen to consist of an incompressible bony mass comprising 

oca put. 




Fig. 541. — Diameters and Landmarks of the Fetal Skull. Upper Surface. 



the face and inferior maxilla, ossification being further advanced here, and 
the compressible vault being attached behind and above, along a line piercing 
the point of juncture of the orbital and squamous parts of the frontal bone, 
and extending backward by the squamous suture, bends downward at the 
junction of the flat part of the occipital bone to its basilar and condylar divi- 
sions. Occasionally one finds supernumerary bones in the interparietal space; 
they are caused by irregular ossification, and are termed Wormian bones. 
Sutures. — The membranous portions between the bones constitute the 



THE FETAL HEAD. 



461 



sutures, which are named according to the bones which they join and the posi- 
tions which they occupy. The sutures are not dovetailed, but are separated 
one from another. The frontal suture unites the two frontal bones ; the coronal 
or fr -onto- parietal sutures join the two frontal with the two parietal bones; the 
great, sagittal, or biparietal suture unites the two parietal bones; and the lamb- 
doid (deriving its name from the likeness of its shape to the Greek letter A), 
or occipito-parietal, joins the occipital and the two parietal bones. Besides 
these there are two others : the temporal or squamous sutures, which are not 
factors in the mechanism of labor, and cannot usually be palpated during the 
process of the same (Figs. 541 and 543). 



BREGMA 




EXTERNAL 
OCCIPITAL PPOTUBERANCS 

Fig. 542. — Diameters and Landmarks of the Fetal Skull. 



Posterior Surface. 



Fontanelles — The point where two or more sutures meet is termed a 
fontanelle. There are two principal ones, namely: (1) The anterior or great, 
also called the bregma and sometimes the sinciput; this space is diamond- or 
kite-shaped, and is found at the point of junction of the frontal, coronal, and 
sagittal sutures. It persists during labor, notwithstanding its somewhat de- 
creased extent caused by the approach of the cranial bones. Four sutures 
run into it ; it averages one inch in diameter and varies widely in size in different 
fetal heads. (2) The posterior or small fontanelle, triangular in shape, is found 
at the point of junction of the lambdoidal and sagittal sutures. This space 
does not persist during labor, being then merely a depression or obliterated 
by the overlapping of the occiput by the parietal bones. Three lines of sutures 



462 



PHYSIOLOGICAL LABOR. 



run into it. Not infrequently by reason of advanced ossification this fontanelle 
is absent. (3) The temporal fontanelles are found at the anterior and posterior 
extremities of the inferior border of each parietal bone (Fig. 540). They 
are irregular in shape and resemble somewhat the occipital fontanelle, and 
may possibly be mistaken for it during labor in cases of lateral obliquity 
of the fetal head (see Part V). (4) False fontanelles are occasionally seen 
either along the line of a suture or in the body of a bone, and are due to imper- 
fect or irregular ossification. They may be mistaken for the principal fonta- 
nelles. In my collection of 34 full-term skulls well-marked false fontanelles 
appear in 4 instances, or 11.1 per cent.; in 33 premature skulls in 5 instances, 
or 1 5.1 per cent. (Fig. 448). 

Movements of the Fetal Head Upon the Spinal Column. — Complete 




Fig. 543. — Diameters and Landmarks of the Fetal Skull. Anterior Surface. 



Flexion. — The head may so bend upon the child's chest that the chin and sternum 
touch each other, giving the condition of complete flexion. The movement of 
flexion is really rotation of the head on a transverse axis. The cause of flexion 
will be found under the subject of Attitude and Mechanism of Labor (Fig. 585). 

Incomplete Flexion. — In certain cases when the head is at the pelvic brim 
and in the third or fourth vertex position, flexion is either partly or entirely 
wanting. Sometimes this condition results from the usual forces not exerting 
their normal degree of action. Imperfect vertical flexion in a flat pelvis will 
be referred to again (Fig. 545). 

Complete Extension. — Again, the head may be bent backward so that the 
occipital protuberance touches the cervical spines without doing any injury 
to the vessels or ligaments of the neck and giving the condition of complete 
extension (Fig. 545). These movements are believed to take place principally 



THE FETAL HEAD. 



463 



in the cervical vertebrae, the occipito-atlantoid articulation taking little or no 
part in them. Antero-posterior motion in some instances certainly amounts 
to as much as 115 degrees. The term incomplete extension explains itself. 

Rotation. — The occipito-atlantoid articulation furnishes the mechanism for 
a very important movement — that of rotation; rotation that allows the vertex 
to move from one point in the pelvis to another, and yet not necessarily re- 
quiring the shoulders to follow this movement. The question as to how great 
a degree of rotation of the head upon the spinal column may take place with 







v v xvy ;# 



occipital 

PROTUBERANCE 





~x> 



















-x. 






— \ 




^5. 






*>: 











■o 




Wm 








^ 




Fig. 544.— -Diameters and Landmarks of the Fetal Skull. Inferior Surface. 



safety to the child has been the subject of much dispute among obstetricians. 
Most of them agree that rotation in the arc of a circle consisting of 90 degrees 
may occur without any injury to the child (Fig. 546), and Tarnier even goes so far 
as to say that rotation in the arc of a semicircle may be made to occur without 
injury. In this case the child's face would look directly backward over its 
spinal column. From experiments with fetal cadavers I find that this rotation 
or torsion is not confined to any single point or joint, but is distributed along 
the upper spinal vertebrae. Ninety-degree rotation of the fetal head during 



464 



PHYSIOLOGICAL LABOR. 






..••ft#\ 



/^^ 



\ 



i w 



labor often occurs without injury to the neck. Fig. 546 is one of several pho- 
tographs of living children I have taken within an hour of delivery to prove 
the harmlessness of ninety-degree rotation of the fetal head. In the present 
case a hundred degrees was easily obtained. 

Lever Action of the Fetal Head. — The head is not evenly balanced upon 
the spinal column. It forms a lever, the chin end of which is the longer, the 
occipital end the shorter, so that this anterior or chin arm tends to fall when 
the head is balanced upon the condyles. The importance of this fact will be 
more manifest when the mechanism of labor is discussed (Fig. 585). 

Moulding. — The result of the pressure of the birth canal upon the fetal 
skull is to diminish the capacity of the whole cranium. This is brought about 

by: (1) The approximation and 
overlapping of the bones of the 
vertex. The bones of the cal- 
varium are not merely joined by 
membrane, as was stated before, 
but there is considerable oppor- 
tunity for overlapping under pres- 
sure, since (a) they ossify late; 
(6) they are separated by sutures 
and fontanelles which permit of 
overlapping; (c) and they are so 
thin as to admit of bending and 
moulding. Overlapping in the 
process of labor always takes 
place in a systematic manner. 
The parietal bones overlap the 
frontal and the occipital bones, 
and the parietal bone which is 
submitted to the greater pressure 
— that is, always the one which 
lies posterior in the pelvis — slides 
under its fellow. (2) The cere- 
brospinal fluid is squeezed out of 
the head into the spinal canal. 
(3) The blood is also forced out 
of the cerebral vessels, to a cer- 
tain extent. (4) Then, too, the 
brain substance itself in the fetus 
is but slightly developed, and is 
therefore capable of being com- 
pressed and moulded to a considerable degree without any permanent damage 
to the fetus. As the fetal head descends lower and lower into the pelvis it 
becomes subjected to an increasing degree of compression and moulding. 
Moulding is further assisted by the hinge produced by the non-ossification of 
the triangular portion of the occipital bone with the basilar portion. 

Diameters of the Fetal Head (Figs. 540 to 544). — For the purpose of 
judging of the changes of shape in the head, and of comparing the head with 
the pelvic dimensions, there are numerical measurements of certain diameters 
of the fetal skull. Problems in the mechanism of labor concern not only the 
size but the shape of the fetal head, and these are best understood, studied, 
and described by the aid of diameters and circumferences taken at different 




OF 



Fig. 545. — Anteroposterior Movements 
the Fetal Head upon the Body. Complete 
flexion; incomplete flexion, incomplete exten- 
sion; complete extension. 



THE FETAL HEAD. 



465 



planes. The most important diameters in case of pelvic deformity are those 
of the base, since they are incompressible. But those to be dealt with in the 
usual case of labor are those having at least one extremity on the vault of the 
skull, and therefore capable of being shortened. The incompressible diameters 
are (i) the bimastoid; (2) the bimalar; (3) the bitemporal. The fetal head 
diameters include (1) the occipito-mental; (2) the occipito-frontal ; (3) the sub- 
occipito-frontal; (4) the suboccipito-bregmatic ; (5) the biparietal; (6) the 




Fig. 546. — Rotation of the Fetal Head upon the Body. The illustration is from one 
of several photographs taken of living children within an hour after delivery to prove 
the harmlessness of 90 degrees or even greater rotation of the fetal head upon the 
body. This photograph shows no degrees rotation. — (Photograph taken by the author 
at the Emergency Hospital.) 



bitemporal; (7) the bimalar; (8) the bimastoid; (9) the fronto-mental ; (10) 
the cervico- or trachelo-bregmatic. 

1. The occipito-mental diameter, O. M., 5§ inches (14 cm.), is the greatest 
distance from the center of the lower margin of the chin to a point on the pos- 
terior extremity of the sagittal suture. 

2. The occipito-frontal diameter, O. F., 4^ inches (11.5 cm.), is measured 
from the apex of the occipital protuberance to the root of the nose. 

30 



466 PHYSIOLOGICAL LABOR. 

3. The sub occipitofrontal diameter, S. O. F., 4! inches (11 cm.), extends 
from the junction of the neck and occiput to the root of the nose. 

4. The suboccipito-bregmatic diameter, S. 0. B., 3! inches (9.5 cm.), is meas- 
ured from the junction of the nucha and the occipital bone to the center of 
the anterior fontanelle. 

5. The biparietal diameter, BI P., 3} inches (9.5 cm.), is the widest distance 
between the parietal protuberances. 

6. The bitemporal diameter, T. T., 3-^ inches (8.25 cm.), is the distance be- 
tween the anterior ends of the coronal sutures. 

7. The bimalar diameter, M. M., 3 inches (7.5 cm.), is the greatest distance 
between the malar tuberosities. 

8. The bimastoid diameter, 3 inches (7.5 cm.), is the widest distance between 
the mastoid apophyses. 

9. The fronto-mental diameter, F. M.,'3i inches (8.25 cm.), is measured 
from the summit of the forehead to the center of the lower margin of the chin. 

The mento-frontal diameter cannot be estimated, as the frontal bone offers 
no fixed point which would serve as one extremity. However, an approximate 
measurement might be stated to be about 3 inches (7.5 cm.), one-half of which 
would span the distance between the glabella * and chin. As the latter one is 
that which is generally brought into relation with the conjugate in a face pre- 
sentation after cranioclasm has been performed, it is most important. 

10. The cervico- or trachelo-bregmatic diameter, 3J inches (9.5 cm.), extends 
from the junction of the neck and chin to the center of the anterior fontanelle. 

These are average measurements taken from many thousand heads, elim- 
inating as far as possible alterations in shape due to moulding of the head in 
its journey through the pelvis, for even after easy labors, with perfectly normal 
vertex presentations, the diameters of the child's head after delivery will 
be decidedly different in relative length from those which have just been men- 
tioned. While these changes in length are usually only relative, yet they 
may at the same time be absolute, chiefly affecting the occipito-mental and 
occipito-frontal diameters. These are increased while all the others are dimin- 
ished, especially the suboccipito-bregmatic and the biparietal. The diameters 
are of value in that they indicate the circumference of the plane of the skull 
in which they are taken. As has been stated, the general shape of the head 
is roughly ovoid, or spheroidal, so that a reasonable idea may be obtained of 
the mass under comparison. The approximate measurements of the more 
important diameters of the fetal head for ease in memorizing and for practical 
purposes may be stated as follows : 

Occipito-mental .5 J inches (14 cm.) Fronto-mental, . . . si inches ( 9 cm.) 

Occipito-frontal, 4J inches (11 cm.) Biparietal, 3^ inches ( 9 cm.) 

Sub-occipito-bregmatic .3^ inches ( 9 cm.) Bitemporal, 3! inches (8.25 cm.) 

Planes and Circumferences of the Fetal Head. — Again, we study 
the shape and size of the fetal head by means of planes or cross-sections cor- 
responding to its diameters, in the same way as we study the pelvis by means 
of horizontal planes at different levels. 

1. The occipito-mental plane (Fig. 550). This section passes through the 
occipito-mental and biparietal diameters; its shape is irregular and oval; its 
circumference is the greatest circumference of the fetal head and equals 15 
inches (38 cm.). 

2. The occipito-frontal plane (Fig. 549)- This section passes through the 

* Glabella, " the space between the eyebrows." 



THE FETAL HEAD. 



467 



biparietal and the occipito-frontal diameters; it is irregularly oval in shape; 
its circumference is 13! inches (35 cm.). 

3. The suboccipito-frontal plane (Fig. 548). This plane passes through the 
bitemporal and suboccipito-frontal diameters; it is also oval and irregular in 
shape; its circumference is 12 inches (30 cm.). 

4. The suboccipito-bregmatic plane (Fig. 547). This section passes through 
the biparietal and suboccipito-bregmatic diameters. This plane is the smallest 




occi PUT 



Fig. 547. — Line of Section and 
Shape of Suboccipito-bregmatic 
Plane. — {Author's lead-tape trac- 
ing.) 



CH 



Fig. 548. — Line of Section and Shape of 
Occipito-mental Plane. — {Author' s lead-tape 
tracing.) 



of all the head planes; is nearly circular in shape, and is the plane which, in 
normal vertex presentations and complete flexion of the head, is successively 
in relation with all the pelvic planes from the inlet to the outlet of the parturient 
canal. Its circumference, after moulding of the head, is 11 inches (28 cm.). 
A study of these cephalic planes and circumferences shows that the circum- 
ference of the suboccipito-bregmatic plane is the smallest, and that of the 
occipito-mental is the greatest of the fetal head circumferences; that any 



468 



PHYSIOLOGICAL LABOR. 



departure from the normal attitude of complete flexion of the head, whereby 
the head is partly extended, increases the circumference of the presenting, 
part anywhere from n to 15 inches, according to the degree of head extension; 
thus making all the difference between an easy, normal labor and complete 
obstruction due to a too great fetal head circumference presenting. 

Trunk Measurements. — The measurements t»f the trunk are unimpor- 




sinciput 



Fig. 549. — Line of Section and Shape 
of Suboccipito-frontal Plane. — {Au- 
thor' s lead-tape tracing.) 



Fig. 550. — Line of Section and Shape 
of Occipito-frontal Plane. — Author's 
lead- tape tracing.) 



tant in average-sized fetuses, because all the diameters are compressible and 
offer little obstacle to delivery (Figs. 551 to 557) 

1. The bisacromial diameter, A. A., 4I inches (12 cm.), is the greatest distance 
between the acromial processes. It is readily compressible an inch. 

2. The bitrochanteric diameter, T. T., 3^ inches (9 cm.), is the widest distance- 
between the trochanters. 

3. The dorso-sternal diameter, D. S., 3-f inches (9.5 cm.), is an antero-posterior 
diameter at the level of the shoulders. 

4. The sacro-pubic diameter y 2^ inches (5.5 cm.), is the antero-posterior 



THE FETAL TRUNK. 



469 



diameter of the fetal pelvis. Flexion of the thighs upon the abdomen doubles 
this diameter, making it 4J inches (11 cm.); it is then compressible an inch 
or more. 

5. The vertico-podalic diameter, V. P., 9^ to 10 inches (24.13-25.4 cm.), is the 
length of the fetal ellipse, and is the greatest distance from the vertex to the 
breech. 

6. The bisacromial circumference — namely, a circumference corresponding 

to the bisacromial diameter — is 13 
inches (33 cm.) (Fig. 554). This is 
compressible several inches. 

Planes and Circumferences of 
the Fetal Trunk. — The bisacromial 
plane is oval with its long axis trans- 
verse (Fig. 554). The midplane of the 
fetal ellipse is an important one, and 
but rarely, if ever, referred to in works 




ANTtRIOR 

Fig. 551. — Lateral Surface of the Nor- 
mal Fetal Ovoid, or Ellipse, showing 
also the Line of Section (i, 2) and 
the Shape of the Midplane of the 
Fetal Ellipse. — {Author's lead-tape trac- 
ing.) 

the knees, elbows, and umbilical cord. 




Fig. 



552. — Anterior View of the Nor- 
mal Fetal Ovoid or Ellipse. 



on obstetrics (Fig. 551). It is a plane 
passing through the center of the fetal 
body and including in its circumference 
Its shape is generally oval, and its 
long axis ant ero -posterior as regards the fetal body. The bitro chanter ic with 
extended thighs is oval with a longer transverse diameter (Fig. 557). When 
the thighs are flexed on the body a more round shape obtains (Fig. 556). 

Length and Weight of the Fully Developed Fetus. — At the for- 
tieth week, or full term, the total length from heels to vertex varies from 18.9 
to 20.47 inches (48 to 52 cm.); the vertex-coccygeal length being about one- 
half of this. The average weight is 6.60 to 7.92 pounds (3000 to 3600 grams); 



470 



PHYSIOLOGICAL LABOR. 



males weighing somewhat more than females and the first child less than sub- 
sequent children, this progressive gain in weight, however, being true only 
till the fourth or fifth child. It must be remembered that variations in the 
weight of the mature fetus occur from 6 to 12 pounds (2700 to 5400 grams); 
in very rare instances 12 pounds (5400 grams) has been exceeded, andweights 
up to 20 pounds (9000 grams) have been observed. 

Attitude or Posture. — A practical point in connection with the part the 
child^plays in the process of labor has to do with (1) the manner in which the 
childis placed in the uterus as regards the relationship existing between its 

own parts, and (2) the relationship 
existing between it and the uterus and 
pelvis. 

Attitude or posture designates the 
relation which the different parts of 
the fetus bear to each other. In the 
normal attitude the bodv is flexed uoon 



Fig- 553- 





Fig. 554- 





Fig. 556. 

Figs. 553-556. — Fig. 553 Shows the Relation of the Long Head Diameter to the 
Long Shoulder Diameter, They being at Right Angles to Each Other. Fig. 
554 Shows the Shape of the Bisacromial Plane. — {Author's lead-tape tracing.) 
Fig. 555 Gives the Posterior View of the Fetal Ovoid or Ellipse, showing 
Lines of Section of Bisacromial Plane (3, 4) and Bitrochanteric Plane When 
the Thighs are Flexed (5, 6). Fig. 556 Gives the Shape of the Bitrochanteric 
Plane, when the Thighs are Flexed. — {Author's lead-tape tracing.) 



itself, rendering the back arched so as to form a convexity backward (Fig. 552). 
It has been shown that from the earliest period the embryo tends to curve 
upon itself, and this flexion persists throughout intra-uterine life (Fig. 132). 
The head is bent upon the sternum: the forearms are crossed or are near one 
another upon the chest ; the thighs and legs are flexed so as to bring the knees 
near the elbows and the feet near the buttocks or breech; the dorsum of the 
foot being somewhat flexed on the leg and the soles of the feet turned a little 



ATTITUDE AND PRESENTATION OF THE FETUS. 



471 



inward; the umbilical cord is generally found in the space between the arms 
and legs, although it may be wound about the neck or body of the child from 
one to several times (Fig. 132). This is the attitude of the later months, but 
in the earlier months, when there is a relatively greater amount of liquor amnii, 
the fetus is not in such a compact mass, nor 
are the extremities so near one another. 

The Fetal Ovoid, or Ellipse. — In consider- 
ing the whole body of the fetus, it may be 
regarded as presenting roughly an ovoid mass 
which is made up of two parts, head and 
trunk, both of the same general shape — 
ovoid. In normal mechanism the long axis 
of the whole mass is almost parallel with the 
axis of the birth canal, and the two axes of 
the two masses respectively, head and body, 
are nearly parallel, one to the other. The 
trunk and breech of this fetal ovoid, or ellipse, 
are bulkier and require more room than does 
the head, which latter, after moulding, is com- 
paratively pointed (Fig. 551). It must also 
be remembered that the fetal ovoid is flat- 
tened from side to side; that its greatest 
transverse diameter is an antero-posterior 
one at about its center or midplane, and 
measured from the spine to the region of 
the flexed arms, legs, thighs, and the coiled- 
up cord (Fig. 551). Attitude is caused chiefly 
by the tonic action of the flexor muscles, for 
they, being the stronger, predominate over 
the extensors, and the primitive attitude of 
the embryo persists. The shape of the uterus 
also offers an etiological factor. According 
to Pajot's law of accommodation: " When a 
solid body is contained in another, if the 
container is the seat of alternate movement 
and rest, if the surfaces are slippery and not 
angular, the contained constantly tends to 
accommodate its form and dimensions to the 
form and capacity of the container." After 
delivery a child will be seen to assume natu- 
rally the prenatal attitude and yet it is free 
to move in any direction. Faulty attitude 
during labor may cause many complications, 
such as incomplete flexion or bregma presen- 
tation; brow and face presentations; lateral 
flexion of the head and prolapse of arms, legs, and cord 
Part V.) 

Presentation. — The term presentation is used to designate that portion of 
the child showing itself most prominently at the os uteri, in the vagina, or 
at the vulva, or it is the relationship of the long axis of the child to the long 
axis of the uterus. 







Fig. 557. — Anterior View of Fetus 
with Extended Arms and Legs. 
Shows line of section (3, 4) and 
shape of bitrochanteric plane when 
thighs are extended. — (Author's 
lead-tape tracing.) 



(See Fetal Dystocia, 



472 



PHYSIOLOGICAL LABOR. 



Table of Pelvic and Fetal Measurements. 
internal measurements of the bony pelvis. 





Anteroposterior 
Diameters. 


Oblique 
Diameters. 


Transverse 
Diameters. 


Circumferences. 


Inlet, 

Middle plane 

cavity, . . 

Outlet 


of 


4$ in. (n cm.). 

5 in. (12.5 cm.). 

3f-4f in. (0.5- 
12 cm.). 


5 in. (12.5 cm.). 
4! in. (12 cm.). 


5iin. (13.5 cm.). 

4f in. (12 cm.). 
4^ in. (11 cm.). 


16 in. (40.5 cm.). 
18 in. (45 cm.). 



Depth of the true pelvis in front is if in. (4 cm.) ; posteriorly 4^ to 5 in. (11.5 to 12.5 
cm.); lateral walls 3^ in. (9 cm.). These measurements of the bony pelvis are lessened 
by the muscles and tissue of the soft parts i to £ inch (0.635 to x - 2 7 cm.). 

CLINICAL MEASUREMENTS OF THE PELVIS. 

Interspinal diameter, . . (Fig. 208) 10 inches (25.5 cm.) . 

Intercristal diameter, (Fig. 209) 1 1 inches (28 cm.). 

Bitrochanteric diameter, (Fig. 209) 12^ inches (31 cm.). 

External conjugate diameter, (Fig. 211) 8 inches (20.25 cm.). 

Right and left external oblique diameters, (Fig. 210) 8f inches (22 cm.). 

Diagonal conjugate diameter, (Fig. 214) 5 inches (12.5 cm.). 

True conjugate diameter, (Fig. 219) 4$ inches (11.5 cm.). 

Transverse of inlet diameter, (Fig. 221) 5^ inches (13.5 cm.). 

Sacropubic conjugate of outlet diameter (Fig. 213) 4! inches (12 cm.). 

Bisischial diameter, (Fig. 215) 4^ inches (1 1 cm.). 

External circumference of pelvis 35J inches (88.75 cm.). 

FETAL HEAD MEASUREMENTS (Figs. 540 to 544). 

Occipito-mental diameter, 5 J inches (14 cm.). 

Occipito-frontal diameter 4$ inches (11.5 cm.). 

Suboccipito-bregmatic diameter 3! inches ( 9.5 cm.) . 

Biparietal diameter 3f inches ( 9.5 cm). 

Bitemporal diameter, 3^ inches ( 8.25 cm.). 

Bimastoid diameter, 3 inches ( 7.5 cm.). 

Fronto-mental diameter, 3^ inches ( 8.25 cm.). 

Cervico-bregmatic diameter, 3! inches ( 9.5 cm.). 



Occipito-mental circumference (Fig. 550) 15 inches (38 cm.). 

Occipito-frontal circumference (Fig. 549) . 13! inches (35 cm.), 

Suboccipito-frontal circumference, (Fig. 548) 12 inches (30 cm.). 

Suboccipito-bregmatic circumference, (Fig. 547) n inches (28 cm.). 

Biparietal circumference, (Fig- 547) I2 inches (30 cm.). 

FETAL TRUNK MEASUREMENTS. 

Bisacromial diameter, 4f inches (12 cm.). 

Bitrochanteric diameter, 3 J inches ( 9 cm.). 

Dorso-sternal diameter, 3f inches ( 9.5 cm.). 

Sacro-pubic diameter, 2& to 4$ inches ( 5.5 to 11. cm.). 

Vertico-podalic diameter, 9J to 10 inches (24.13 to 25.4 cm.). 

Bisacromial circumference, 13 inches (33 cm.). 



PRESENTATION OF THE FETUS. 473 

f Vertex, Bregma. Brow, Face. 

' Anterior Parietal Bone, Posterior Parietal 



I. Cephalic ] Bone 

I Excessive flexion. 
Classification n. p e lvic j Breech. 

OF 

Presentations. 



III. Trunk { Shoulder. 

IV. Complicated { Prolapse of cord; one or more arms or legs. 

C Head and breech. 

V. Multiple \ Two heads, two breeches. 

I Head or breech and shoulder or abdomen. 

Relative Frequency. — The frequency of vertex presentations is 96 per cent, 
of all presentations; the pelvis or breech presents in from 3 per cent, to 4 
per cent, of all cases; face presentations occur in 0.5 per cent.; shoulder pres- 
entations in 0.5 per cent.; and brow presentations in 0.25 per cent, of all cases. 

We have no reliable figures to offer for the relative frequency of complicated 
and multiple presentations. 

Causes of Frequency of Vertex Presentations. — The etiology of the usual 
presentation, — the vertex, — considered the normal since it is present in 96 per 
cent, of all cases at full term, is readily understood. It is well established 
that the head is generally lower than the breech, even from the very first 
formation of the liquor amnii. It has been shown that in the early months 
frequent changes occur in the position of the fetus in utero, that these changes 
become less and less marked as full term approaches, until at that period the 
proportion of head presentations far exceeds in frequency any other. According 
to Churchill's statistics, head presentations occur in 83 per cent, of living and 
only 53 per cent, of dead fetuses at seven months. Changes from other pre- 
sentations to the vertex are more frequent than the converse, and a shoulder 
is more often changed than a breech, the causes being the shape of the fetus 
and uterus and uterine contractions. 

In 175 miscarriages (third to seventh month) I found the proportion of 
cephalic and podalic presentations usually divided. In 238 premature children 
including living, still-born, twins, and still-born and macerated, I found the 
following : 

Cases. 

Cephalic (vertex) presentation, 129 or 54.20 per cent. 

Podalic (breech) presentation 55 or 23.12 per cent. 

Shoulder presentation, 7 or 2.95 per cent. 

Not noted on history, 47 or 19.23 per cent. 

Total 238 

In the total number of 238 premature children, including the twenty twin 
cases: 

Cases. 

Fetus was born living 114 or 47.89 per cent. 

Fetus was still-born, 47 or 19.75 P er cent. 

Fetus was still-born and macerated 43 or 18.07 per cent. 

Condition not noted on histories 34 or 14.29 per cent. 

Total 238 

Vertex. Breech. Shoulder. 

Living children, 3 I -5° P er cent. 9.24 per cent. 0.84 per cent. 

Still-born, 9.24 per cent. 5.88 per cent. 1.26 per cent. 

Still-born and macerated, 8.82 per cent. 6.30 per cent. o per cent. 

This last table shows markedly the predominance of vertex presentations 
in fetuses born alive (31.50 per cent, vertex, and 9.24 per cent, breech, in living 



474 PHYSIOLOGICAL LABOR. 

fetuses; moreover, the sharp decline in the excess of vertex presentations over 
breech when a still-born or still-born and macerated fetus obtains (9.24 per 
cent, vertex and 5.88 per cent, breech in the former, and 8.82 per cent, vertex 
and 6.30 per cent, breech in the latter). 

As pregnancy approaches term the presentation becomes progressively more 
and more stable, and particularly so in primigravidae, because the head descends 
lower in the pelvis, and the abdominal walls, being more rigid, prevent move- 
ments to any extent.* 

Gravity is an important factor in determining the position of the head at 
the cervix. The fetus is immersed in a fluid not much lighter than itself (liquor 
amnii, specific gravity 1.01). With these conditions the effect of gravity 
will depend not upon the position of the center of gravity of the child when 
suspended in air, but upon the relative specific gravity of the different parts. 
Matthews Duncan proved that the specific gravity of the head is greater than 
that of the headless trunk. 

Other causes of head presentation exist, and one is the shape of the uterine 
cavity and the law of accommodation, for the fetus in vertex presentation 
takes up less room than in any other position. Although in the middle third 
of pregnancy the pregnant uterus is nearly round, yet in the last third it becomes 
more and more pear-shaped or pyriform, with the broad part directed upward 
and the tapering extremity downward. In the study of the fetal ellipse it 
has been seen that it consists of a broad extremity, the breech, and the narrowed 
part, the head. In the adaptation of the fetus' body to the uterine cavity, 
a head or vertex presentation results. Since the uterus is so elastic and con- 
tractile, when the long axis of the child lies transverse or oblique, uterine action 
tends to make it parallel with the long axis of the uterus, accommodating the 
bulky breech to the roomy fundus and the smaller pointed head and vertex 
to the narrowed and less roomy lower uterine segment. 

Reflex action on the part of the child plays its part in causing the head 
to lie lowest. In the case of breech presentation the sensitive buttocks and 
feet are constantly exposed to the jars caused by movements of the mother, 
as well as to the augmented uterine contractions of the lower part of the uterus 
caused by the extreme stretching to which it is subjected by a breech in the 
latter part of gestation. 

The intermittent uterine contractions, which increase in force and frequency 
as gestation advances, help in securing a head presentation, assisted by the 
shape and attitude of the fetus and the bulk and mobility of the fetal head. 
The sum of the force of intra-uterine pressure is toward the lower uterine seg- 
ment, and hence the head, being mobile, is forced down in that direction. 

Summary. — The following are the causes of vertex presentation, enumerated 
in the order of their importance: (1) The shape of the uterine cavity; (2) 
the shape of the fetal ellipse; (3) the intermittent uterine contractions; (4) 
the mobility of the fetal head; (5) the direction of intra-uterine force; (6) 
gravity; (7) reflex action. Alterations- in the normal action of any one of 
these important causes may result in departures from a normal vertex pres- 
entation. The shape of the uterine cavity may be changed by tumors, pelvic 
deformity, low implantation of the placenta, hydramnios, and multiple preg- 
nancy. The normal shape of the fetal ellipse may be changed by hydrocephalus, 

* Schroeder, however, from observations made in 214 primigravidae, including four 
cases of contracted pelvis, found during the last three weeks of pregnancy changes of pres- 
entation occurring in 36.4 per cent. 



POSITION OF THE FETUS. 475 

and by tumors of the neck and trunk. Gravity and reflex action are affected 
by the death of the fetus. 

Position. — The term position is used to define the relationship existing 
between a certain point on the presenting part, and certain other points on 
the pelvis of the mother. The points on the presenting parts are the occiput 
in vertex presentations; the sacrum in breech presentations; the chin in face 
presentations; the frontal bone in brow presentations, and a scapula in shoulder 
presentations respectively. The four fixed cardinal points on the mother's 
pelvis are the two acetabula in front and the two sacro-iliac synchondroses 
posteriorly (Figs. 520 and 521). The positions in all presentations are named 
numerically, beginning at the left acetabulum and passing to the right, and 
thus around the pelvis; as the first, second, third, and fourth. There are, 
therefore, four positions for each presentation, according as the single point 
on the presenting part corresponds to one of the four cardinal points on the 
mother's pelvis. For example: in the right mento-posterior position the chin 
is the point on the presenting part, and the right sacro-iliac synchondrosis 
is the point on the pelvis of the mother. This is the third position in face 
presentation. 

POSITIONS OF THE FETUS. 
VERTEX POSITIONS. 

I. Left Occipito-anterior — Occipito Laeva Anterior, L. O. A., 70 per cent. 
II. Right Occipito-anterior — Occipito Dextra Anterior, R. 0. A., 10 per cent. 

III. Right Occipito-posterior — Occipito Dextra Posterior. R. O. P., 17 per 
cent. 

IV. Left Occipito-posterior — Occipito Laeva Posterior, L. O. P., 3 per cent. 

FACE POSITIONS. 

I. Left Mento-anterior — Mento Laeva Anterior, L. M. A., second in fre- 
quency. 

II. Right Mento-anterior — Mento Dextra Anterior, R. M. A., third in 
frequency. 

III. Right Mento-posterior — Mento Dextra Posterior, R. M. P., most com- 
mon. 

IV. Left Mento-posterior — Mento Laeva Posterior, L. M. P., fourth in fre- 
quency 

BROW POSITIONS. 

I. Left Fronto-anterior — Fronto Laeva Anterior, L. F A. 
II. Right Fronto-anterior — Fronto Dextra Anterior, R. F. A. 
III. Right Fronto-posterior — Fronto Dextra Posterior, R. F. P. 
IV. Left Fronto-posterior — Fronto Laeva Posterior, L. F. P. 

PELVIC POSITIONS. 

I. Left Sacro-anterior — Sacro Laeva Anterior, L. S. A. ? most frequent. 
II. Right Sacro-anterior — Sacro Dextra Anterior, R. S. A. 

III. Right Sacro-posterior — Sacro Dextra Posterior, R. S. P., second in 
frequency. 

IV. Left Sacro-posterior — Sacro Laeva Posterior, L. S. P. 

SHOULDER POSITIONS. 

I. Left Scapula Anterior — Scapula Laeva Anterior, L. Scap. A., most 
frequent . 



476 



PHYSIOLOGICAL LABOR. 



II. Right Scapula Anterior — Scapula Dextra Anterior, R. Scap. A., 

III. Right Scapula Posterior — Scapula Dextra Posterior, R. Scap. P. 

IV. Left Scapula Posterior — Scapula Laeva Posterior, L. Scap. P. 

In Germany two positions of the vertex are described: The first vertex position (I 

Schadellage) is when the occiput lies to 
the left side of the pelvis, and the second 
vertex position (II Schadellage) is when 
it lies to the right. The Germans con- 
sider our third and fourth positions to be 
variations of the first and second. In 
France four positions are described, as 
with us, and, in addition, right and left 
transverse positions, making six in all. 
In England, as in America, four posi- 
tions are described. On the Continent 
of Europe — namely, in France and Ger- 
many — and also in America the right 
oblique diameter of the pelvic inlet starts 
from the right sacro-iliac synchondrosis 
and the left from the left. In England, 
on the contrary, the reverse obtains; 
namely, the right oblique diameter ends 
at the right ilio-pectineal eminence, and 
the left is that which ends at the left emi- 
nence. 

These are facts which must be re- 
membered in reading German, French, 
and English works on obstetrics. 




Fig. 558. — Axial Torsion of the Pregnant 
Uterus and Shape of the Uterine Cavity. 
Note that the long transverse diameter of 
the uterus corresponds to the right oblique 
pelvic diameter, thus bringing the left bor- 
der of the uterus and the fetal back (in L. 
O. A.) toward the anterior abdominal wall. 
(Compare Figs. 162 and 559.) 



Relative ^Frequency. — In all pre- 
sentations, with the exception of the 
shoulder, the first and third posi- 
tions most frequently obtain. In 
other words, at the pelvic inlet the 
long diameter of the presenting part 
lies in a diameter of the uterus which corresponds to the right oblique diameter 
of the pelvic inlet, with the dorsum of the fetus directed to the left and an- 
terior or to the right and posterior. In vertex presentations the first position 
obtains in 70 per cent, of cases, the second in 10 per cent., the third in 17 per 
cent., and the fourth in 3 per cent. 
In face presentations the first posi- 
tion is second in frequency; the 
second position, third in frequency; 
the third most common, and the 
fourth position is fourth in fre- 
quency. In shoulder presentations 
the first position is most common. 
In pelvic or breech presentations 
the first is the most frequent and 
the third is second in frequency. 
1 Explanation of the Frequency of 
the First Vertex Position. — The 
anterior part of the cavity of the 
uterus is better adapted to accom- 
modate the posterior plane of the 

fetus, while the posterior part, which is encroached upon by the prominent 
lumbar vertebrae, is more fitted to receive the anterior part of the fetal ellipse. 
This is why the child's back most usually presents anteriorly. But if for any 




Fig. 559. — Axial Torsion of the Uterus 
and Shape of the Uterine Cavity. 



POSITIONS OF THE FETUS. 477 

reason the uterus should be uniformly pear-shaped, and not be possessed of 
those peculiarities just mentioned, then the back of the fetus may look to 
the back, front, or either side (Fig. 558). 

We know that the longest horizontal axis of the uterus is a transverse one; 
in other words, that the uterine cavity in the latter part of pregnancy is flattened 
from before back (Fig. 135). In this connection also the torsion of the uterus 
on its longitudinal axis, whereby the left lateral aspect inclines toward the 
front, must be taken into account (Fig. 558).* The result of axial torsion is 
to bring the roomy transverse diameter of the uterus into coincidence with 
the right oblique diameter of the pelvic inlet. A glance at the fetus in its 
normal posture (Figs. 551 and 552) will show that its greatest horizontal diam- 
eter is an ant ero -posterior one; namely, from a point on about the center of 
the curved back to the anterior plane formed by the legs, arms, and umbilical 
cord. In other words, as frozen sections prove, the fetal ellipse is flattened 
laterally (Fig. 552). This is true for all presentations with the possible excep- 
tion of the shoulder. From this it will be readily seen that accommodation 
or adaptation will cause the largest transverse diameter of the fetal ellipse 
to correspond to the roomiest horizontal diameter of the uterus. Hence the 
antero-posterior diameter of the fetal ellipse must correspond to the transverse 
diameter of the uterus, and torsion of the uterus causes this latter to coincide 
practically with the right oblique of the pelvic inlet. The presence of the two 
parts of the bowel, the sigmoid flexure and the rectum, through which the 
feces so often pass, is sufficient to account for the oblique position of the pre- 
senting part, whether the back lies anterior or posterior, and so to explain the 
usual positions — left anterior or right posterior. 

Although the transverse diameter of the bony inlet is by actual measure- 
ment the longest, still this long diameter passes just in front of the promontory 
of the sacrum, and the head enters the plane of the inlet half-way between 
the symphysis and sacrum, and here the diameter is less than 5 J inches (Fig. 
521). These facts account for the head lying in one or the other of the oblique 
diameters. Another factor is also present, and that is the encroachment of 
the muscles, the ilio-psoas in particular, on the inlet of the pelvis (Fig. 533). 
This makes the transverse diameter of the superior strait less capacious than 
the oblique. This, too, then accounts for the predominance of oblique fetal 
positions regardless of the presentation. It has been determined that these 
muscles decrease the transverse diameter by about 1.5 cm. (0.5906 inch) and 
the conjugate by 1 cm. (0.3937 inch). The most frequent positions of the 
fetus therefore are the first and third, the former being most frequent for reasons 
stated above. 

We may sum up the causes of the greater frequency of the first and third 
positions as follows: (1) The flattened shape of the fetal ovoid; (2) the shape 
of the uterine cavity; (3) the axial torsion of the uterus; (4) the shortening 
of the left oblique diameter of the pelvis by the sigmoid and rectum; (5) the 
diminution of the transverse diameter of the pelvis by muscles and sacral prom- 
ontory; (6) the greater roominess of the right oblique diameter. 

* Various causes for this axial rotation have been suggested: (i) the position of the 
descending colon and the sigmoid flexure, which are often distended with fecal matter; 
(2) the embryological development of the uterus; (3) the fact that the right round liga- 
ment is shorter and more highly developed than its fellow; (4) the greater frequency of 
the right lateral position of the patient. 






478 PHYSIOLOGICAL LABOR. 



III. THE EXPELLING FORCES. 

The expelling forces consist, first, of the voluntary or auxiliary forces, which 
include the anterior and lateral abdominal muscles, diaphragm, and pelvic 
floor; and, second, of the involuntary forces, which consist of the contractions 
of the uterus and of the round and broad ligaments. 

i. The Voluntary or Auxiliary Forces. — (i) Abdominal Muscles and Dia- 
phragm. — The abdominal muscles and diaphragm in contracting increase the 
intra-abdominal pressure and give efficient assistance to the efforts of the uterus. 
These forces come into play with the second stage of labor, and are at first, 
almost purely voluntary, but later on, toward the end of the second stage, 
they are reflex by nature.* This increased abdominal pressure tends to force 
the uterus with its contents downward, in a line whose direction is that of the 
axis of the pelvic inlet. Action: Their action is as follows: In the process 
of labor the patient draws a deep inspiration, thus flattening the diaphragm; 
the glottis is closed and the diaphragm becomes fixed and contraction of the 
abdominal muscles takes place. As a result of the descent of the diaphragm 
the fundus is pressed forward so that the uterine axis is practically in line with 
that of the pelvic inlet. In the last part of the expulsive period, when the 
pains continue for several seconds, the patient is forced to open the glottis 
for breath; the abdominal pressure is by this action relieved until closure 
of the glottis once more takes place. At times, when the pain becomes unen- 
durable and the patient is forced to cry out, the glottis is again opened, so 
it may happen that in the course of one uterine pain there are several abdominal 
contractions. Harvey, experimenting on dogs, and de Graaf on rabbits, in 
order to show that the fetus is expelled by the "vis uteri propria" opened 
the abdomen at term; nevertheless the animals expelled their young without, 
of course, the aid of the abdominal muscles. Haller has seen spontaneous 
expulsion of young in the case of pregnant females a short time after death. 
(See Post-mortem Delivery.) Harvey, Smellie, and others have reported cases 
of spontaneous labor in paraplegic women. Although the voluntary and reflex 
contractions of the abdominal muscles are not an indispensable factor in labor, 
nevertheless they accelerate the expulsion. It is undoubtedly true that the 
application of forceps is often necessary on account of the feebleness of the 
effort which is expended — for instance, in women with hernia. 

I have repeatedly observed and demonstrated to students the second stage 
of labor terminated without the co-operation of the abdominal muscles at all; 
still, the action of these muscles is most important in the expulsion of the pla- 
centa, especially after it has left the uterus. At this period it is held by some 
that the contractions of the vagina also assist in expelling the placenta, but 
others are convinced that the only action possessed by the muscles of the vagina 
is that which restores this canal to its original shape after the passage of the 
fetus. It can be clearly seen of what assistance also the abdominal contractions 
are in completing the birth of the child in breech cases, when the after-coming 
head has passed below the retracted fundus. 

(2) The Vagina and Pelvic Muscles. — At term the musculature of the vagina 
is hypertrophied to a considerable extent and is important in the expulsion 
of any part of the ovum that can be acted on by peristalsis. The periods when 

* It was at one time held that the abdominal wall was the sole cause of the birth of 
the child; later it was taught that it played no part, but Schroeder showed that both uterine 
and abdominal contractions were concerned in the expulsion of the fetus. 



THE EXPELLING FORCES. 



479 




Fig. 560. 



-Shape of the Uterus during a 
Uterine Contraction. 



its action is most valuable are during the expulsion of the after-coming head 
and of the placenta. The only pelvic muscles of the pelvic floor concerned 
in expulsion are the levator ani, the transversi, the sphincters of the vagina 
and of the anus. Their action is imperfectly peristaltic and assists the muscle 
of the vagina. 

2. The Involuntary Forces, or Uterine Contractions. — The uterus, during the 
contractions of the second stage, is 
retained in its position by means of 
the round ligaments, which are com- 
posed chiefly of involuntary muscle- 
fibers, assisted by the muscular part 
of the broad ligaments. In con- 
tracting, the round ligaments tend 
to force the fundus downward and 
forward, and by their action on the 
upper part of the uterus they are 
one factor in the increase of intra- 
uterine pressure. After the uterus 
has been raised by the round liga- 
ments, however, abdominal pressure 
can act to better advantage. 

(1) Involuntary. — Although the uterine contractions have no dependence 
on the will, — i. e., they are involuntary, — they may be considerably influenced 
by the brain, as may be seen by the effect of mental emotions. 

(2) Peristaltic. — Like other organs composed of non-striated muscle, the 
contractions are assumed to be peristaltic in nature, probably passing from 
the Fallopian tubes down to the cervix. Some believe that the contractions 

pass in the opposite direction from 
the cervix up. The waves succeed 
each other so quickly that the whole 
uterus is in action at the same time. 
From observations on the lower ani- 
mals it is believed that the direction 
is from above downward, and the 
uteri of rabbits, for example, being 
of a long, tubal form, act just like 
a length of intestine. It is the 
general belief that the contraction 
of the human uterus is not peri- 
staltic. I have repeatedly attempted 
to determine this point in Csesarean 
section cases, but the contractile 
segment was so instantaneously in- 
volved that no peristaltic wave could 
be demonstrated. 
^3) Intermittent. — The contractions are intermittent; each contraction be- 
gins, reaches its acme, and then subsides, the length of time occupied by one 
"pain" depending upon the stage of labor in which it occurs, the average dura- 
tion being about a minute; the variations being between thirty and sixty 
seconds. The interval between contractions is about thirty minutes at first, 
but decreases to between two and three minutes at the end of labor. The con- 




Fig. 561. — Shape of the Uterus during the 
Period of Relaxation. 



480 PHYSIOLOGICAL LABOR. 

tractions are rhythmical in their intermission — there is an approximate regu- 
larity about them. In this respect there is a variation in the same ratio as 
the length of the single pains. During labor the contractions gradually in- 
crease in severity, duration, and frequency. At the beginning of labor the 
duration of the contractions is about twenty seconds. Toward the end of 
the second stage the duration is a minute or more. In some cases, after the 
uterine contractions have continued for some hours, they cease for a correspond- 
ing period, after which they once more become vigorous. 

(4) The contraction presents three stages: (a) increment, (6) acme, (c) de- 
crease; or a stage of contraction, a stage of persistence, a stage of decline. 
About twenty years ago Schatz studied the contractions by means of a rubber 
bag and kymograph, inserting the bag between the membranes. He found 
that the curve representing the contraction was round at the top, there being 
no true acme. The normal intermittence in the course of the contractions 
is a most necessary feature for the welfare of both mother and fetus. The 
latter would succumb to asphyxiation were the contractions continuous, and 
the mother would not be able to endure the long agony were it not alleviated 
by periods of rest. She would also be subject to much injury of her tissues, 
and rupture of the uterus would almost surely occur. The musculature of 
the uterus also would not receive its nourishment and it would lose its irrita- 
bility. This alteration of work and rest in the uterus has its analogue in the 
action of many other organs, — e. g., the heart, intestines, and brain, — these 
conditions seeming to be one of the essential characteristics of living organs. 

(5) The Uterus Changes in Form and Position. — Changes in form and posi- 
tion of the uterus are also associated with its contractions. Its shape becomes 
cylindrical during a contraction; the longitudinal and the antero-posterior 
diameters are increased to a slight degree, while the transverse is distinctly 
decreased. This latter, shortening somewhat, extends the fetus; its curvature 
is lessened and thus causes an increase in the longitudinal diameter, causing 
partial extension of the fetal ellipse. The effect of the contraction of the round 
and broad ligaments on the uterus has been noted on page 479 (Figs. 560 and 

561). 

(6) Proportionate to the Resistance. — The force of contractions increases 
with the advancement of labor; the length of the contractions increasing as 
the length of the interval decreases. The pain caused by contraction against 
resistance is generally proportionate to the resistance, though not invariably 
so, for in primiparas in whom there is great resistance this state is usually coun- 
terbalanced by the superior quality of the uterine musculature. The opposite 
conditions are present in multiparas. In the second or third labor conditions 
bear a more favorable relation to each other than at any other time. 

(7) Vary with the Presentation. — The character of the contraction varies 
with the presentation. In vertex presentations the contractions possess more 
regularity and efficiency, and may even be termed characteristic of normal 
labor; in face, brow, breech, and shoulder presentations irregularities are usually 
manifest, so that the physiognomy of labor is well worth a careful study. For 
in order to obtain normal characteristics there must be uniform pressure on 
the lower uterine segment and the os, and this is not exerted in breech, face, 
brow, or shoulder presentations; hence the facies in labor will often give the 
keynote to the presentation. 

(8) The Pain of Uterine Contractions. — -The contractions are painful, this 
being their most striking characteristic. It has given rise to the term "labor 
pain." It is a well-known fact that in the majority of cases the first pain occurs 






THE EXPELLING FORCES. 481 

between ten and twelve o'clock at night. The cause is not known. As to 
the character of the pains, it differs with the stage of labor in which the pain 
occurs. They are at first quick, sharp, and colicky, and are due chiefly to the 
dilatation of the cervix, and are felt usually in the sacral region, where pain 
originating in the cervix is almost invariably referred. After the os has been 
dilated they become "bearing down" in quality, and are then efficient in ex- 
pelling the fetus. As to the intensity of the pains, that will depend on the 
nervous constitution of the patient. They are generally more severe in prim- 
iparae, especially during the stretching of the vagina and vulva. Pain is also 
caused by resistance of the brim, and by the strain to which the attachments 
of the uterus are subjected. To this is added the pressure by the heavy uterus 
on the nerve plexuses in the pelvis, and that on the nerves of the vagina by 
the presenting part. The abdominal muscles also are the seat of pain on account 
of their contractions, which are cramp-like. Pain is also probably caused 
by compression of the ends of the nerves which lie between the contracting 
fibers. Werth advances the suggestion that another cause is spinal neuralgia 
resulting from the anemic condition of the lower cord and meninges. 

(9) False Contractions or Pains. — These are contractions, sometimes pain- 
less, at others very painful, which are generally localized in the abdomen, and 
as a rule take place in multiparae. They occur a short time before labor begins 
and generally in the early hours of the night. They have no effect in causing 
dilatation nor are they accompanied by the "show." The "show" consists 
of the discharge of bloody mucus. The plug which has been closely held in 
the cervical canal for some months is loosened with the advent of cervical 
dilatation and is discharged from the vagina. The blood originates from the 
rupture of the cervical vessels. 

(10) Pulse and Arterial Tension. — There is an increase in pulse-rate during 
a uterine contraction, but it gradually decreases at the close. Arterial tension 
is increased on account of the amount of blood that is driven from the uterus 
to the general circulation. Respiration grows less frequent during a pain, 
but increases in the intervals. The temperature of both uterus and body is 
a little increased during a contraction. 

Strength of Uterine Contractions. — Schatz * found that the pressure on the dynamometer 
was 20 mm. mercury, while 15 mm. of this are due to the weight of the fluid. At the 
height of the contraction it ranged to 100 mm. Considerable resistance has to be over- 
come by the uterine contractions. If we measure the amount of force necessary to rupture 
the membranes outside the body, we will have an approximate estimate of the force of 
the contractions. Matthews Duncan's work was carried on with a piece of membrane 
about 4 inches in diameter placed over a cylinder connected with an anemometer. His 
results varied from 5 to 37 pounds (2100 to 17,000 grams). In some cases a force equal 
to the mere weight of the fetus accomplished the rupture; in others considerable force 
was required. Polaillon's method: In this the surface of the membranes was estimated 
as 217 square inches (1400 sq. cm.). Pressure exerted by the uterus amounts to 338.8 
pounds (154 kilos), 88 of which are due to uterine contractions and the rest to the weight 
of the fetus. Another method gave him the force of each pain as 19.8 pounds (9 kilos), 
and for the whole labor 965.8 pounds (439 kilos). Duncan estimated that the force 
in a whole labor was 40 or 50 pounds (18 to 22 kilos), and the effort which must be made 
to hold back the head gives these figures. He also estimated the amount of force which a 
child can endure, and found that there was no change till 90 or 100 pounds was reached. 
After this the cervical vertebras are dislocated and 30 pounds (about 14 kilos) more will 
sever the head. Hence the force in labor must be less than this figure. In his estimations 
Poullet made use of the tocograph, and Dr. Henry Leaman, of Philadelphia, invented an 
instrument which he called the parturiometer, for measuring the force of uterine con- 
tractions. This last instrument I experimented with for two years, but was never able 
to arrive at any satisfactory conclusions. 

* The instrument used by Schatz was called the tocodynamometer. 
31 



482 PHYSIOLOGICAL LABOR. 



IV. THE ETIOLOGY OF LABOR. 

As the fetus becomes older there is more carbonic acid given off, which 
acts as a stimulus. With the excess of carbonic acid there is less oxygen in 
the blood of the placenta, and by these means the uterine motor center in the 
medulla is affected. Changes in the decidua are necrotic in their nature. There 
is a fatty degeneration which supervenes near the end of gestation in many 
cases, but this is not constant. Eventually the ovum becomes a foreign body. 
This theory was advanced by Naegele and others, and the view appears to be 
a rational one. Eden regards all the changes in the placenta as senile which 
finally cause it to become a foreign body. Leopold found marked thrombosis 
of the vessels in the decidua. He considered that this finally causes an increase 
in carbonic acid which soon causes contractions. Some believe that when 
the uterine musculature is completely developed labor begins, but we see uterine 
contractions in abortion and premature labor. Still another view is that after 
the uterus has been distended to a certain extent there comes a reaction, and 
the process of retraction begins and the fetus is expelled. But this does not 
clear up the matter, since the thickness of the uterus varies in different subjects 
and in the same subject in different pregnancies. Then, too, the uterus is 
distended by hydramnios and multiple pregnancies far more than in normal 
pregnancy, and still the general rule holds good that the fetus is born when 
it becomes mature — not before, not afterward. Spiegelberg advances the 
explanation that certain substances in the maternal blood which in the early 
part of pregnancy the fetus has made use of, accumulate, since the nearer the 
fetus comes to maturity, the less use it has for these same substances. As 
it reaches the point of maturity and needs other forms of nutrition which it 
is now unable to obtain, this fact, as well as the accumulated material in the 
mother's blood which acts upon the motor centers of the uterus, militates for 
its speedy expulsion. Since Braxton Hicks published his observations on the 
constant contractions of the uterus, these various theories have been less con- 
vincing. He claimed that the contractions take place after the uterus appears 
above the symphysis pubis, and during labor these contractions are accentuated. 
The function of these contractions in pregnancy is not known, but at the end 
of pregnancy they expel the fetus from the uterus. Pohlman held that as 
long as the fetus was immature and attached to the uterus it forms a part of 
the maternal organism, at least in effect; but when full maturity is attained 
it becomes a foreign body and is expressed by uterine contractions. The causa- 
tion of labor is a very complicated question, and we are to-day ignorant of 
the actual determining factor, through the operation of which a uterus, after 
remaining comparatively quiescent for thirty odd weeks, suddenly and perhaps 
unexpectedly takes it upon itself to get rid of a burden it has carried so long 
without rebellion. 

It is probable that there are several predisposing causes, and that the real 
direct or exciting cause is some slight circulatory or nervous disturbance brought 
on by overexertion, an overdose of cathartic, a misstep, straining at stool or 
micturition, or mental excitement. 



THE STAGES OF LABOR. 483 



V. THE STAGES OF LABOR. 

It is customary to divide labor into three periods or stages: namely, first, 
second, and third, and designated respectively, stage of dilatation, of expulsion, 
and last of placental delivery and uterine contraction and retraction. To 
these we add, without assigning it a number, another; namely, the preparatory 
stage. 

The preparatory stage of labor extends from subsidence or sinking of the 
uterus until true labor sets in, and begins about two weeks before true labor 
in primigravidae and ten days before in multigravidae. Its phenomena consist 
in (i) sinking of the uterus, the so-called "lightening"; (2) gradual shortening 
of the cervix and dilatation of the internal os, and (3) false or spurious labor 
pains. 

1. In the sinking of the uterus the organ sinks lower in the pelvis, the fundus 
drops forward, and the head either engages or sinks down to the pelvic floor. 
Deep engagement of the head is more marked and more constant in primi- 
gravidas by reason of the tense abdominal muscles, strong uterine muscles, 
and greater intraabdominal pressure. In both primigravidae and multigravidae 
we often observe the head distending and pushing down into the pelvis the 
thinned anterior wall of the lower segment, with resulting posterior displace- 
ment of the cervix, so that the os looks backward and upward. This is the 
so-called sacciform dilatation of the anterior part of the lower uterine segment 
(Fig. 790). This change affords great relief to the woman; her respiration 
is less embarrassed, her clothes are looser, and her digestion is improved. The 
irritability of the bladder and rectum become more marked; mucus pours 
from the vaginal and cervical glands and is generally a very good indication 
of the progress of the dilatation of the cervix. 

2. The gradual shortening of the cervix and dilatation of the internal os. The 
cervix, as a rule, retains its entirety until the thirty-sixth or thirty-eighth week 
of gestation ; up to this time the cervical canal is one inch long, the external 
and the internal openings are closed, the supra-vaginal and infra- vaginal por- 
tions are present very much as in the non-pregnant state. The greater intra- 
uterine pressure and distention of the lower uterine segment in primigravidae 
causes a gradual expansion and unfolding of the supra-vaginal cervix at about 
the thirty-sixth week; but in multigravidae, because of the previous distention 
of the lower uterine segment, pressure is not so readily communicated to the 
margin of the internal os, and dilatation here does not commence until about 
the thirty-eighth or thirty-ninth week. At the end of gestation in primigravidae 
the internal os has usually expanded and disappeared for the reception of the 
ovum; this is much less often the case in multigravidae. In pathological in- 
stances of overdistention, such as hydramnios and multiple pregnancy, the un- 
folding and complete disappearance of the internal os is most clearly shown, 
and is in some instances, nearly complete. (See the Parturient Tract, page 

450-) 

3. The false or spurious labor pains are the normal intermittent uterine 
contractions of gestation occurring more frequently than usual, with greater 
intensity and accompanied by pain. They are often caused by a temporary 
indigestion or rectal distention, and hence are often relieved by a laxative 
or enema. They are distinguished from true uterine pains by their temporary 
character, irregularity, being felt generally over the abdomen instead of in the 
lumbo-sacral region or just above the pubes; by not progressing in frequency 



484 



PHYSIOLOGICAL LABOR. 



and severity and in not causing any hardening or dilatation of the os. The 
most definite symptom of the commencement of labor is the presence of uterine 
contractions or pains, recurring at intervals which gradually decrease in length, 
while the force of the contractions increases, and causing a gradual thinning 
and dilatation of the cervix. 

i. The first stage of labor, or stage of dilatation, extends from the onset of 
true labor pains to the complete dilatation or dilatability of the os. The dura- 




Fig. 562. — Frozen Section after Sudden Death from Cerebral Abscess, during 
the First Stage of Labor. Age of patient thirty-seven years; 7-para; fundus 
uteri 3 inches above the umbilicus; internal os dilated to admit two fingers. The 
section is a vertical mesial one with the frozen fetal parts of the opposite side placed 
in exact superposition. Note the posture of the fetus and moulding of the head, 
the latter being well above the pelvic floor; also the lower borders of the peritoneum 
anteriorly and posteriorly; the beginning formation of the "bag of waters," and 
the contraction ring; and the distended rectum. — (William C. Lusk's case.) 



tion of this stage is variable ; it may be as short as two hours or it may continue 
several days. The length is influenced by the age of the patient and by the 
number of children she has borne, it being longest in elderly women, especially 
primiparae. The average duration for primiparae is often stated to be sixteen 
hours, though it may be much longer; while for multiparas an average of nine 
hours may be quoted. The phenomena of this stage are (1) true uterine con- 
tractions or labor pains; (2) a muco-sanguineous discharge; (3) the mech- 
anism of cervical dilatation; (4) the formation of the caput succedaneum. 



THE STAGES OF LABOR. 485 

i. The true labor pains cause the patient to assume different attitudes; 
she is restless, often walking about from place to place and emitting cries on 
the occurrence of a "pain," very different in character from those of the later 
stages. The contractions or "pains," which at first are not very annoying, 
occur about every half hour, and are accompanied generally by pressure sen- 
sations. At first the pain is apt to be felt in the region of .the sacrum, which 
is the common location for pain originating from any cervical trouble, and 
it may radiate to the lower abdomen or down the legs. Generally the first 
pains come on in the early part of the night, and in character they closely re- 
semble the false pains which are often felt in the last weeks of pregnancy. The 
woman is frequently more impatient of the pains of dilatation than she is of the 
later ones, because she fails to see that any progress is being made, although 
the passage of the head over the exquisitely sensitive perineum causes the 
most excruciating agony experienced during all the course of labor. The 
patient often vomits or shivers at this stage; there is an abundant secretion 
of urine; the cervix grows gradually more patulous till its edges become con- 
tinuous with the walls of the vagina. When the diameter of the opening reaches 
about three inches, the descending "bag of waters" ruptures, allowing a little 
of the liquid to escape, while the remainder is kept back by the ball valve-like 
action of the head. The temperature rises slightly and the pulse of the patient 
increases during a uterine contraction, but the fetal heart-beat is slowed at the 
height of a pain. 

2. The muco-sanguineous discharge. All of the secretions, both vaginal 
and cervical, are increased with the progress of labor, and they serve as a lubri- 
cant to the passages. As the lower uterine segment and the cervix expand 
the lower part of the membranes is separated from the wall of the uterus, giving 
rise to a slight hemorrhage which streaks the mucous discharge, and early 
in labor the bloody mucus is known as the " show." 

3. The mechanism of cervical dilatation (Figs. 563 to 571). According to well- 
known hydrostatic laws, the pressure of the uterine walls in the state of contrac- 
tion is communicated to the fluid in the bag of waters in a generally uniform man- 
ner, barring the variations which occur at different levels, and which are due to 
the weight of the liquid (Fig. 572). There is no propulsion till the cervix begins 
to be dilated, and then the bag of waters is forced, to a certain degree, out 
of the os, the fetus in itself not being acted upon, but the force is expended 
on the entire ovum (Fig. 573). The direction of the force is in the central 
axis of the os and in a line perpendicular to its plane. The uterus acts in 
two ways: (1) when it contracts its internal area is diminished, and the result 
is intrauterine fluid pressure caused by the force exerted on the fluid within 
the ovum; (2) after rupture of the membranes, and the consequent escape 
of fluid, there occurs direct contact between the fundus and the breech, and, 
indeed, this may very occasionally occur before the membranes are ruptured. 
The abdominal muscles assist the uterus in both these forms of action; they 
add their part to the force exerted by the uterus before the membranes are 
ruptured as well as after this event takes place. The os may be said to be 
dilated normally by the protruding bag of waters; this being the case when 
the fluid is abundant and the membranes are unruptured. When these con- 
ditions are present, the intrauterine fluid pressure has no effect on the fetus; 
this can be inferred from the law in hydrostatics that fluid pressures, whatever 
the cause, are always equal and opposite in all directions; hence the fetus is 
not affected by contractions of the uterine musculature. Although the lower 
uterine segment makes an effort at contraction, it is forced open at the os by 



486 



PHYSIOLOGICAL LABOR. 






Fig. 563. — Primiparous 
Cervix at the Begin- 
ning OF UTERINE CON- 
TRACTIONS. 



Fig. 564. — Primiparous 
Cervix Early in Labor. 



Fig. 565. — Cervix in Mul- 
tipara at Beginning 
of Uterine Contrac- 
tions. 






Fig. 566. — Multiparous 
Cervix Early inJ Labor. 



Fig. 567. — Primiparous 
and Multiparous Cer- 
vix. Dilatation for 
Two or Three Fin- 
gers. 



Fig. 568. — "False Wa- 
ters." Fluid between 
Chorion and Uterine 
Wall above and be- 
tween Chorion and 
Amnion Below. 






Fig. 569. — Primiparous or 
Multiparous Cervix. 
Os One-half Dilated. 
Internal Os drawn up 
into Lower Uterine 
Segment. 



Fig. 570. — Rupture of 
the Membranes. i, 
Usual site; 2, just inside 
the os; 3, within the 
uterus. 



Fig. 571. — Formation of 
a Second Bag of 
Waters. 



THE STAGES OF LABOR. 



487 



the power of the upper strong part. It is well known that the lower uterine 
segment is by far the weakest part of the uterus, and so, during contraction, 
its tendency is to expand ; this being the effect of the intrauterine fluid pres- 
sure. That part of the area of the uterus which is opposite the vagina is not 
supported by the intra-abdominal pressure nor by the abdominal muscles, 
both of which factors hold sway above. In this way not only is the centrifugal 
force increased, but the centripetal force is diminished. Another feature which 
adds to the weakness of this part of the organ is the os — an opening in the 
uterine wall much weaker than the Fallopian tube openings. So that, indeed, 
the very first effect of uterine contractions is seen in the expansion of the lower 
uterine segment. While the internal os and upper cervix and supravaginal 
portion are dilating, the bag of waters begins to bulge through the os, and 



i .1 i 




Fig. 572. — General In- 
trauterine Pressure 
during a Uterine Con- 
traction, before Rup- 
ture of the Mem- 
branes. _ The X and — 
signs indicate the results 
of general intrauterine 
pressure. 



A — 




— A 



Fig. 573. — Further Result 
of General Intrauter- 
ine Pressure. The lower 
segment is weakened, 
thinned, and dilated. 
A, A, and B indicate the 
directions of the remain- 
ing pressures. 




Fig. 574. — Still Further 
Result of the General 
Intrauterine Pressure. 
The fetus is partially ex- 
pelled from the cervix, 
and the uterus in conse- 
quence shortens and be- 
comes thicker in its upper 
part. A, A, Lateral uter- 
ine pressure; B, direct 
pressure of the thickened 
fundus upon the fetal axis. 



the fluid pressure can then act directly on its edges. 
This process gradually proceeds till the internal os 

disappears, the cervix shortens till it also is abolished, and then the mem- 
branes act directly on the external os. The force exerted by the membranes 
is directly proportional to their convexity. This can be explained by the 
law in physics that the fluid pressure is opposite and equal in all points, and 
is exerted at right angles to any surface against which it acts. Consequently 
the rapidity of dilatation will correspond with the degree of bulging of the 
membranes through the os. After the membranes are ruptured these laws are 
applicable to the force exerted by the head in causing dilatation. These facts, 
together with that of the successively increasing force of uterine contractions, 
explain why the last stages of dilatation are nearly always more rapid than 
the first. To refer back to what was called the normal mechanism of the 
first stage, — the membranes being unruptured, — the progress of the first stage 



488 



PHYSIOLOGICAL LABOR 



of labor is chiefly due to the first form of uterine force, the intrauterine fluid 
pressure, while the membranes act only as dilators. The second form has not 
yet been called into play, — direct pressure of the walls on the child, — neither 
is the voluntary action of the abdominal muscles often present, so the intra- 
uterine fluid pressure due to the general intra-abdominal pressure always 
exerted by the tonicity of these muscles is to be looked upon as the important 
factor in causing the progress of labor at this stage. 




Fig. 575. — Central Separation of the 
Placenta from the Uterine Wall, 
with the Formation of a Retropla- 
cental Blood-mass. (Schultze's mech- 
anism.) 



Fig. 576. — Descent of the Placenta 
Doubled upon Itself, with the Center 
of the Fetal Surface Presenting. 
(Schultze's mechanism.) 




Fig. 577. — Descent of the Placenta with 
the Lower Border First, through the 
Cervix and Vagina. (Duncan's mech- 
anism.) 



Fig. 578. — Complete Separation of the 
Placenta. The placenta is expelled flat 
with the lower margin first presenting. 
(Duncan's mechanism.) 



4. Caput succedaneum. If this stage is prolonged, a scalp tumor forms 
on that portion of the head least subjected to pressure, due to venous conges- 
tion and oedema. (Compare Part IX.) 

2. The second stage of labor, or stage of expulsion, extends from the com- 
plete dilatation or dilat ability of the os to the complete expulsion of the fetus. 
The duration of this stage varies from a few minutes to six hours or more. Its 
average duration in primiparae is from two to three hours, and in multiparas from 



THE STAGES OF LABOR. 489 

one to two hours. The phenomena of this stage consist in: (i) Characteristic 
uterine contractions; (2) the use of voluntary forces; (3) the descent of the 
presenting part ; (4) the dilatation of the vagina ; (5) the dilatation of the vulva ; 
(6) the expulsion of the fetus. 

1 and 2. Uterine contractions and the use of voluntary forces. The nature of 
the contractions is entirely changed ; they are far more severe than in the first 
stage, and are bearing-down in character; the voluntary forces are now utilized; 
the patient makes use of the diaphragm and the abdominal muscles ; she braces 
herself for every paroxysm and holds tightly to whatever support may be at 
hand. The cry differs also from the earlier one, the patient often taking a quick 
inspiration in the midst of a pain in order to be able to resume the expulsive 
effort, this being accompanied by a characteristic grunt or the whole ended by a 
moan. The pains are now efficient, and as the fetus is driven out through the 
dilated cervix the vagina relaxes to receive it. When the perineum is reached, 
its firm but elastic structures bulge with every uterine contraction and recede 
with its subsidence. The pelvic floor directs the presenting part upward and 
forward toward the orifice of the vulva. Mucus lubricates both the passages 
and fetus, and thus the vagina more easily allows the onward movement of the 
fetus. Between the pains the soft parts press back the fetus till the presenting 
■part is so firmly fastened under the symphysis pubis that this cannot recur. 
Finally the vulva gapes ; the presenting part is seen ; the anus relaxes and the 
rectal wall appears ; there is an uncontrollable desire to micturate and defecate 
due to pressure on bladder and rectum; there comes the crowning effort, and the 
head passes through the external opening (Fig. 597). The fundus uteri now quickly 
subsides and the uterine muscle is in close contact with the parts of the fetus 
still contained within it. At this stage there generally occurs a slight pause, 
varying in duration. There is sometimes a cry at the expulsion of the 
head and sometimes the patient makes no sound; when present, this has been 
known as the physiological cry. 

3. The third stage of labor, or stage of placental delivery and uterine con- 
traction and retraction, extends from complete expulsion of the fetus to com- 
plete expulsion of the placenta and membranes. The average duration of this 
stage is, when spontaneously completed, about one hour. Immediately after 
birth the patient feels calm and comfortable. Now and then there is a feeling 
of faintness caused by the sudden evacuation of the uterus. The phenomena 
of the third stage are: (1) characteristic uterine contractions; (2) the control 
of hemorrhage; (3) the separation of the placenta; (4) the expulsion of the 
placenta; (5) the physiological chill. 

1. Uterine contractions. After the completion of the second stage the uterus 
may be palpated in the hypogastrium, and should resemble a firm, round, ball- 
shaped body, and more or less tonic as well as rhythmic contractions should 
be present, although the latter are not necessarily felt by the woman as " pains." 
The hardness of the uterus varies at this time and after the expulsion of the 
placenta, but the risk of hemorrhage is not necessarily great unless there is 
much relaxation between the intermittent contractions, or sudden gushes of 
blood occur during or between the contractions. 

2'. The control of hemorrhage at this time is primarily due to the constriction 
of the vessels by the firm and tonic uterine contractions, and secondarily to 
coagulation of the blood in the mouths of the vessels. 

3. Placental detachment. At or just before the expulsion of the fetus, the 
placenta is partially detached from the uterus. Shrinkage of the placental 
site and the forcing downward of the whole placental mass by uterine con- 



490 PHYSIOLOGICAL LABOR. 

tractions account for this separation. The usual and I believe normal manner 
of placental delivery is for it to be folded on itself by the contracting uterus, 
so that the long axis of the placenta corresponds to the long axis of the uterus, 
and the margin that presents at the cervix, vagina, and vulva is the lower 
margin, showing perhaps a little of its fetal surface (Duncan's method) (Figs. 
577' 57S). Occasionally, especially when traction has been made upon the cord, 
the center of the fetal surface with the attached cord presents first, like an 
inverted umbrella (Schultze's method) (Figs. 575, 576). It makes very little 
difference, from a practical standpoint, how the placenta is born. 

4. Placental expulsion occasionally occurs with or just after the birth of 
the fetus; usually, however, in purely spontaneous placental delivery, an hour 
or even more intervenes between the fetal and the placental delivery. During 
this time the uterus should be moderately hard as the result of tonic contraction, 
and intermittent or rhythmic contractions, though not strongly marked, should 
be present, thus causing the uterus to vary in hardness. The intermittent 
contractions after a short time become stronger, nearer together, and finally 
are felt as " pains " by the patient, and a little blood is expelled by them from 
the vagina. In spontaneous expulsion these contractions finally complete pla- 
cental separation and force the placenta down so that it lies partly in the 
flaccid, relaxed cervix and partly in the vagina. In the absence of inter- 
ference its expulsion from the vulva is accomplished by the voluntary forces, 
aided by the contractions of the uterus and vagina. 

5. Physiological chill. Not uncommonly some slight shivering, in some cases, 
— about 15 percent., — even passing into a decided chill, takes place shortly after 
the placental delivery. It is more often observed after rapid deliveries, and 
may continue from a few minutes to a quarter of an hour, and is unattended 
by any alterations in the pulse or temperature. Its best explanation is that 
the organism, or rather the abdomen, loses a large mass to which it had been 
previously accustomed, the result being that the internal viscera are no longer 
compressed, and we have a rapid rush of blood from the exterior to fill the 
space left in these organs. Consequently a more or less severe chill results, 
which is entirely physiological and is not a signal of danger. 



VI. THE MECHANISM OF LABOR. 

Definition. — The mechanism of labor is the manner in which the fetus passes 
through the parturient canal; and it has to deal with the hard and the soft 
parts which compose the latter and with the fetus and the expelling forces. 
It treats of the movements of the fetus through and out of the parturient canal, 
and the causation and character of these movements. 

Importance. — Familiarity with the three factors of labor — namely, the 
passages, the passenger, and the forces — is essential in order to appreciate 
the combination of movements known as the mechanism of labor by which 
nature guides the fetus from the uterine cavity through the pelvis into the 
external world. With equal success might we hope to appreciate and treat 
certain cardiac diseases without an understanding of the anatomy and physi- 
ology of the heart, as to attempt the management of labor cases without a clear 
knowledge of the mechanism of parturition. It is true that one ignorant of 
the mechanism of labor may successfully care for cases of normal confinement ; 



THE MECHANISM OF LABOR. 



491 



it is equally true, in other instances, that this want of knowledge results in 
disaster to mother and fetus. 

But one mechanism of labor. From a mechanical standpoint all labors are 
subject to the same physical laws and follow these laws, provided only that 
expulsion occurs, spontaneously and at term, of a normal-sized fetus, and 
through a normal pelvis; in premature labors and in cases of monstrosities 
and deformed pelves many departures from the usual mechanism occur. It 
may' be stated, then, that there is but one mechanism of labor for all. The 
mechanism of the first vertex position (L. O. A.) may be looked upon as the 




Fig. 579. — The Mechanism of Labor. The Head in the Left Occipito-anterior 
Position on the Pelvic Floor before Anterior Rotation and Dilatation of 
the Vulval Orifice. 



standard; and the mechanism of the other three positions of the vertex, and 
the several positions of the breech, face, and brow, as following the same general 
standard. 

Six Stages. — Six clearly defined stages of mechanism in all presentations 
and positions, with the exception of shoulder presentation, can usually be 
demonstrated. These stages are: (1) Moulding; (2) engagement and descent; 
(3) rotation of the first part of the fetal ellipse; (4) expulsion of the first part 
of the fetal ellipse; (5) rotation of the second part of the fetal ellipse; (6) expul- 
sion of the second part of the fetal ellipse. 



492 PHYSIOLOGICAL LABOR. 

i. Moulding. — In the first stage the fetus, pressed upon and influenced 
by the general intrauterine pressure, and perhaps also to a slight extent by 
the voluntary efforts of the mother, tends to accommodate, to mould the shape 
of its presenting part to suit the canal through which it has to pass. This 
moulding in vertex presentation is accomplished by overriding of the bones 
of the vault of the skull and by actual change of the shape of the brain ; in brow 
presentations the same causes operate; in face presentations, the bones of 
the face proper change very little, although a characteristic moulding of the 
frontal, parietal, and occipital bones occurs, and swelling and oedema of the 
facial tissue assists in the acquired general shape of the head; in breech pres- 
entation moulding is entirely due to compression of the soft tissues. 

II. Engagement and Descent. — Engagement of the head in the pelvis 




Fig. 580. — The Mechanism of Labor. The Head in the Left Occipito-anterior 
Position on the Pelvic Floor. A caput succedaneum has formed, anterior rotation 
has just begun, and partial dilatation of the parturient outlet has taken place. — 
(Studdi ford's frozen section at the Emergency Hospital.) 

in vertex presentations, especially in primigravidae, often occurs before labor 
sets in. Engagement and descent occur more readily and promptly in ante- 
rior positions of the vertex and with moderate-sized fetuses. Delayed engage- 
ment and descent we observe in posterior positions of the vertex; in primary 
or secondary inertia of the uterus ; in excessive uterine obliquity and torsion ; 
in brow presentations, since a greater circumference presents; in face and 
breech presentations because these parts are irregular, are poor dilators, and 
are subject to cedematous swelling. Naturally engagement and descent in 
any presentation or position are favored by undersized fetuses and roomy 
pelvic inlets. 

III. Rotation of the First Part of the Fetal Ellipse. — All explana- 
tions of internal rotation apart from the fetus may be classed as (1) uterine 



THE MECHANISM OF LABOR. 



493 



and (2) pelvic. The uterine theory attributes a rotation force to the uterus 
itself. The pelvic explanation takes into account the shape of the pelvis — 
as determined by the ischial spines and planes and varying lengths of the 
pelvic diameters — and the shape, resistance, and actions of the structures going 
to make up the perineal floor. The anatomical investigations of J. Veit * 
and H. Varnier f deny to the shape of the pelvis — namely, the varying lengths 
of the various planes — and even to the bones of the pelvic outlet any influence 
on the internal rotation of the head. The latter explains the rotation of the 




Fig. 



581. — The Mechanism of Labor. The Vertex is Dilating the Parturient 
Outlet after Anterior Rotation of the Occiput — "Crowning." 



head as due exclusively to the arrangement of the muscles of the pelvic floor 
and the perineum. 



Desiring to test for myself experimentally the part the pelvic floor plays on anterior 
rotation of the presenting part, I undertook the following experiments: I screwed a swivel 
into the head of a fetal cadaver half an inch behind the small fontanelle, attaching a yard 
of cord to the ring of the swivel. I repeatedly dragged the head through the pelvis of 
a woman dead after recent delivery. The occiput invariably rotated to the front, even 
when the head entered the pelvis in the posterior positions, so long as the pelvic floor re- 
tained its integrity. When the tonicity of the floor became impaired by overstretching, 

* "Die Anatomie des Beckens im Hinblick auf den Mech. d. Geb.," 1887. 
t "Du Detroit Inferieur musculaire du Basin obstetrical," Paris, 1888. 



494 



PHYSIOLOGICAL LABOR. 



the head traversed the pelvis in very nearly the same position at it had entered.* In 
making use of the term complete rotation of either head or shoulders in these observations, 
it was not meant that mathematically complete rotation resulted, but only such as pal- 
pation or inspection determined, unaided by more exact means of measurement. Leish- 
man's researches with a cord stretched from symphysis to coccyx showed that exact co- 
incidence of the sagittal suture and the antero-posterior diameter of the pelvic outlet 
failed in many instances. The well-known experiments of Paul Dubois consisted in push- 
ing fetal cadavers of various sizes through the birth canal of a puerpera recently dead. 
He found that the occiput turned forward, provided the pelvic floor was not injured by 
rupture or overstretching. Repetition of his experiments overstretched the floor, and 
then rotation failed. 

Rotation was complete and readily accomplished in the first of my experiments; then, 



t 




Fig. 582. — The Mechanism of Labor. Extension of the Head through the Par- 
turient Outlet. 

as the muscles and tissues became more and more stretched and relaxed as the result of 
repeated pressure upon them, I found rotation first incomplete and finally failing to occur 
altogether. Given the normal attitude of the fetus (extreme flexion of the head) and 
good expulsive powers, and the most important remaining condition for forward rotation 
and a normal mechanism is a firm pelvic floor. 



A clear mental picture of the shape of the fetal ellipse and of the parturient 

canal is absolutely essential to the further understanding of the mechanism 

of parturition. One should always recollect: (1) The fetal ellipse is made 

up of two parts, a bulkier but more compressible body, and a relatively smaller 

* Edgar: "The Mechanism of Labor," loc. cit. 



THE MECHANISM OF LABOR. 



495 



but less compressible head; these parts are readily movable in their relation 
to each other so as to produce degrees of flexion and extension and of torsion 
and rotation (Fig. 551). (2) The antero-posterior diameters of the head are 
the largest diameters (Fig. 552). (3) While it is true that the greatest diameter 
of the non-compressed fetal body is the antero-posterior one at the level of 
the umbilicus, still the greatest diameter of the shoulders is the bisacromial, 
4| inches (12 cm.) (Fig. 554); and at the breech, the bitrochanteric, 3^- inches 
(9 cm.) (Fig. 557). (4) The most dependent portion in a vertex presentation 



/ 




Fig. 583. — The Mechanism of Labor. Internal Rotation of the Shoulders and 
External Rotation of the Head, or "Restitution." The unsupported head 
permits the birth of the anterior shoulder first. 



is the occiput; in a face presentation, the chin; in a brow presentation, the 
brow; in a breech presentation, the buttock which lies in the anterior segment 
of the pelvic cavity; and of two shoulders, the one in the anterior pelvic seg- 
ment. (5) The greatest resistance of the pelvic floor is found in the posterior 
segment; the levator ani muscle with other muscles and tissues of the pelvic 
floor enter into the formation of a scoop-like body with the greatest resistance 
behind a line joining the spines of the ischii ; the tendency and function of which 
by resistance and contraction are to guide and direct whatever comes in contact 
with it anteriorly toward and into the vulval slit, the weakest and least resistant 



496 PHYSIOLOGICAL LABOR. 

portion of the pelvic floor. (6) The parturient canal possesses an irregular, 
corkscrew-like shape, (a) The fetal ellipse rests with its greatest (antero- 
posterior) diameter in the greatest (transverse) diameter of the uterus. Torsion 
of the uterus swings the left side of the latter forward so that the fetal back 
points midway between the left and front (Fig. 558). (b) The roomiest diam- 
eter of the parturient pelvic inlet is the oblique (Fig. 559); into this the pre- 
senting part enters, (c) The roomiest diameter of the parturient pelvic cavity 
is still the oblique; through this the presenting part travels, (d) The roomiest 
diameter of the bony and parturient outlet is the ant ero -posterior diameter 
(Fig. 522); this, the long diameter of the presenting part seeks, assisted by 
the greater resistance of the posterior segment of the pelvic floor and the shape 
of the entire segment. (7) From the foregoing it follows: (a) that the 
longest horizontal diameter of the uterus is the transverse diameter, ren- 
dered oblique in its relation to the pelvic inlet by the torsion of the 
uterus on its vertical axis; (b) the long diameter of the parturient pelvic 
outlet does not correspond with that of the inlet, hence a torsion, a rota- 
tion of the portion of the fetal ellipse passing from one to the other in 
order to obey the law of physics and travel in the direction of least re- 
sistance occurs ; (c) whatever portion of the presenting portion of the fetal 
ellipse first strikes the pelvic floor, whether it encounters this structure in front 
of or behind a median transverse diameter, will be directed forward under the 
symphysis pubis and into the vulval slit; (d) it is undoubtedly the fact that 
it is not one factor alone, but several, that determine this rotation. Accommo- 
dation, adaptation, the great principle that runs through all the mechanism 
of labor, whereby the long diameter of the presenting part adapts itself to 
the long diameter of that part of the pelvis in which it may find itself; the 
corkscrew-like arrangement of the pelvis; the lessened resistance caused by 
the urethral and vaginal orifices in front ; the greater resistance of the thicker 
and heavier tissues in the posterior half of the pelvis; the inclination of the 
pelvis; the shape of the child's head; the inclination of the uterus causing 
the anterior part of the presenting portion to reach the pelvic floor first — all 
play their part in the causation of anterior rotation. 

Deep Transverse Position. — Not uncommonly in elderly multiparas with lax 
soft parts one observes a deep transverse position of the sagittal suture or 
bitrochanteric diameter; namely, the head or breech advances through the 
lower part of the pelvis, and even up to the orifice of the vulva, in a transverse 
or oblique position, and internal rotation occurs only at the very last moment 
in the vulval orifice. This possibility must ever be kept in mind in medium 
and low forceps operations upon the head in vertex, face, and brow presenta- 
tions; for the lateral pelvic walls are 3^ inches (9 cm.) deep, and the distance 
from shoulders to occiput in vertex presentations, from shoulders to chin in 
face, and to forehead in brow, does not exceed three inches, and so further 
descent in transverse positions without rotation and escape of the presenting 
part would draw the chest into the pelvis with the head, and the dorso-sternal 
diameter, 3} inches (12 cm.), added to the presenting head diameter, would 
result in impaction, and traction with the forceps would greatly endanger 
the life of the fetus and the soft parts of the mother. 

IV. Expulsion of the First Part of the Fetal Ellipse. (See Patho- 
logical Labor.) — This is the head in cephalic presentations and the trunk 
in breech presentations. The manner of expulsion of the head will depend 
upon the presentation and position. In occipito-anterior positions the head 
is expelled by a movement of extension in front of the pubis; in permanent 



THE MECHANISM OF LABOR. 497 

occipito-posterior positions, by a movement of extension over the edge of the 
perineum; in mento-anterior positions of face presentation, the head flexes 
in front of the pubis ; in permanent mento -posterior positions impaction occurs 
and no expulsion results. In brow presentations the same general mechanism 
as in occipital presentations obtains. In breech presentations the sacro-perineal 
curve and the drawing forward of the presenting part by the levator ani muscle 
cause a lateral flexion of the trunk during its expulsion (compare Fig. 136). 

V. Rotation of the Second Part of the Fetal Ellipse. — This occurs 
(1) in the trunk in cephalic presentations, and (2) in the head in breech pres- 
entations. 

1. The internal rotation of the trunk in cephalic presentations, vertex, face, 
and brow, naturally causes an external rotation of the expelled head. Internal 
rotation of the head in breech presentation does not so constantly cause external 
rotation of the trunk by reason of the greater weight and bulk of the latter. 
In cephalic presentation — namely, vertex, face, and brow — when the trunk is the 
second part to be expelled, the shoulders, we have every reason to believe, enter 
the pelvic inlet in the oblique diameter opposite to the one in which the head 
entered ; or, if the head entered in a transverse diameter, it is possible, in a roomy 
pelvis and with a child that is not too large, for the shoulders to enter in the 
opposite diameter or in the ant ero -posterior diameter of the inlet. At all 
events, we usually find the shoulders first in an oblique diameter, and the anterior 
portion of the presenting part, because of the direction of the axis of the superior 
strait, is lower than is the posterior; consequently it is this part that first reaches, 
and is influenced by the resistance at, the floor of the pelvis and is deflected 
anteriorly to the pubic arch. If both shoulders came to the pelvic floor at one 
and the same time, we have every reason to believe that they would both be 
equally influenced by the factors which cause anterior rotation, and consequently 
the bisacromial diameter would remain in the same diameter in which it entered 
the pelvic inlet. Observation has taught me that while complete anterior 
rotation of the head is the rule, yet complete rotation of the shoulders is not 
by any means so constant as is that of the head. I made observations * upon 
sixty-seven primiparae and seventy multiparas as regards the internal rotation 
of the bisacromial diameter, and found that complete rotation occurred once 
in 1.3 cases in primiparae, and once in 1.2 cases in multiparas. It will be seen 
from the above that complete rotation occurs with about equal frequency 
in primiparae and multiparas. Even before the shoulders begin to rotate inter- 
nally we see an unwinding, as it were, of the muscles of the neck that have 
been twisted in the internal rotation of the fetal head, and as a consequence 
the head makes a partial movement of external rotation, and this first partial 
movement of rotation is termed "restitution." When the shoulders rotate 
within the pelvis, there must, in consequence, be a decided rotation on the 
part of the head which is already delivered, and this further and more marked 
rotation of the head is termed external rotation of the head, whereby in vertex 
L. O. A. position the face of the child looks almost directly to the inner surface 
of the right thigh of its mother. 

2. Head rotation in breech cases. In breech presentations when the head is 

the second part to be expelled, the long diameter of the head enters the pelvis in 

the opposite diameter to that in which the bitrochanteric of the breech engaged. 

Provided the head continues flexed upon the sternum, when the pelvic floor 

is reached, rotation of the occiput to the pubis and of the face to the hollow of 

the sacrum occurs, in all but about 1.5 per cent, of cases, no matter what the 

* "The Mechanism of Labor," loc. cit. 
32 



498 PHYSIOLOGICAL LABOR. 

original direction of the occiput at the inlet. What is the explanation of 
this rotation? I believe it is to be found at the occipital end of the head, 
which is the most prominent and consequently the most positively influenced 
by the pelvic floor. A glance at a cast of a fetus in its normal attitude will 
demonstrate the prominence of the occiput (Fig. 551). If the forehead were 
most in evidence, then the opposite rotation would occur. 

VI. Expulsion of the Second Part of the Fetal Ellipse. — This is 
the delivery (1) of the trunk in cephalic presentations, and (2) of the head 
in breech presentations. 

1. First, as to the delivery of the trunk in trunk-last cases, R. Lefour be- 
lieves the posterior shoulder, as a rule, is born first. Auvard found that in 
29 cases the posterior shoulder came first in 16 and the anterior in 9 cases. 
He recommends in all cases support of the head in order to prevent its own 
weight interfering with the natural progress of the expulsion of the body. Leonet 
asserts that the anterior shoulder first disengages in 90 out of 100 cases if the 
fetal head be not supported; that the posterior shoulder first emerges in 90 
out of 100 cases if the head be supported. He states that the danger to the 
perineum first begins upon the disengagement of the posterior shoulder. Re- 
garding shoulder delivery, I made observations on 69 primiparae and 68 mul- 
tiparas, and found that the posterior shoulder was born three times as often 
as the anterior in primiparae and two and a half times as often in multipara?. 
In almost every one of the above cases, however, the head upon delivery was 
lightly supported by the hand; this support results in favoring the birth of 
the posterior shoulder first. The posture of the woman does not appear to 
affect the mechanism of shoulder deliver}-, as my observations upon 15 cases 
of spontaneous delivery in primiparae and 28 in multiparae in dorsal and lateral 
postures seemed to prove. 

2. Head expulsion in head-last cases. (See page 584.) 



VII. THE DURATION OF NORMAL LABOR. 

The onset of true labor is not always readily determined. Occasional false 
labor pains are often experienced for days or even weeks before the diagnosis 
of true labor pains can accurately be determined. It must be granted, how- 
ever, that shortening and dilatation of the cervix often go on during this time. 
On the other hand, active labor may cease entirely for hours during the first 
stage without harm to mother or child. The duration of the several stages, 
as well as the total duration, varies within wide limits in different individuals. 
Labor is generally one-third shorter in multiparae than in primiparae, on account 
of the soft parts offering less resistance after previous labors. The duration 
of the spontaneous first stage may be approximately stated as ten to fourteen 
hours in primiparae, and six to ten hours in multiparae; of the second stage, 
two hours for the former and one hour for the latter. The duration of the 
third stage varies from a few minutes to two hours ; the average being about 
half an hour. It is rarely spontaneously completed in this country. An ob- 
stetric tradition holds that labor is especially prolonged in elderly primiparae 
(thirty to forty years). The statistics of Courtade of the Tarnier Clinic (1900) 
and the author's show that labor in elderly primiparae is but slightly longer 
on the average than in primiparae in general. (See Maternal Dystocia.) 



LIVE BIRTH— FEIGNED DELIVERY. 



499 



The following table gives the average duration of spontaneous labor in 
544 primiparse and 910 multiparas, and the average duration in 47 elderly primi- 
parae from among the lower and laboring classes of New York. 



Primiparae, . 

Multiparas. . 

Elderly Pri- 

miparae . . 



Average 

Duration 

First Stage. 



Average 
Duration 

Second Stage. 



Average 

Duration 

Third 

Stage. 



Shortest 

Total 
Duration. 



Longest 

Total 
Duration. 



13 hrs. 15 1 hr. 36 , 38 mm. | 1 hr. 30 j 55 hrs. 20 
min. min. min. min. 



9 hrs. 

15 hrs. 
min. 



1 hr. 

min. 
1 hr. 43 

mm. 



2 32 mm. 
22 min. 



40 mm. 



45 hrs. 



mm. 
2 hrs. 10 : 53 hrs. 35 
min. min. 



Average 

Total 
Duration. 



15 hrs. 29 

min. 
1 1 hrs. 4 

min. 
15 hrs. 49 

min. 



Of the primiparae, the longest duration of the first stage was fifty-four hours; 
the shortest, forty-five minutes. Of the 544 labors, the second and third stages 
took place practically together in two cases. Of the multiparas, the longest 
duration of the first stage was forty-four hours; the shortest, thirty minutes. 
The second and third stages took place practically together in three cases. 
Of the elderly primiparae, the longest duration of the first stage was fifty-three 
hours twenty minutes; the shortest, fifty minutes. The longest total duration 
of labor was fifty-three hours thirty-five minutes; the shortest, two hours 
ten minutes. Of the 47 cases, in no instance did the placenta follow imme- 
diately the birth of the child (see Maternal Dystocia). 



VIII. LIVE BIRTH. 

By live birth is meant simply that the fetus was born alive, and the defi- 
nition of the term is entirely independent of the viability of the child, which 
latter term indicates the capability the child possesses of continuing to live. 
A strict medico-legal rendering of the term live birth ignores entirely the imma- 
turity, viability, and maturity of the child, and requires an answer only to 
the question, Was the fetus at the moment of expulsion alive? The test of 
a live birth differs in various countries; in Germany, crying "attested by 
unimpeachable witnesses"; in France, respiration; in Scotland, crying; in 
England and the United States neither breathing nor crying is essential to 
establish a live birth; the pulsation of the child's heart, or of one of its arteries, 
or the slightest voluntary movement is regarded as sufficient for this purpose 
(Reese). In regard to crying as a test of live birth, Coke remarks: "If it be 
born alive it is sufficient, though it be not heard to cry, for peradventure it 
may be born dumb." Legally, all we require for a live birth is anything to 
prove that the child was alive at the time when it entered the world. 



IX. FEIGNED DELIVERY. 

From a variety of motives, as for extorting damages or charity, compelling 
marriage, disinheritance, obtaining admission to some charitable institution, 
or for no assignable reason, women may simulate or feign delivery of a child. 



500 PHYSIOLOGICAL LABOR. 

A careful examination of these cases if the simulated delivery is said to be 
recent, and if the various doubtful, probable ; and certain signs of recent delivery 
are excluded, will clear away all doubt.* (See Signs of Recent Delivery, Part 
VI) This condition in the lower animals is quite common, and has been repeat- 
edly observed by dog-breeders. I have observed the phenomenon in the breed- 
ing of Scotch terriers. Years ago Harvey, in writing upon conception, stated 
that overfed bitches, which admit the dog without fecundation following, are 
nevertheless observed to be sluggish about the time they should have whelped, 
and to bark as they do when their time is at hand, also to steal away the whelps 
of another bitch, to tend and lick them, and also to fight fiercely for them. 
Others have milk or colostrum in their teats, and are, moreover, subject to 
the diseases of those which have actually whelped. 



X. UNCONSCIOUS DELIVERY. 

The possibility of a woman giving birth to a child even at full term, and 
remaining, for a time at least, unconscious of the fact, must be granted. The 
possibility of unconscious delivery is especially important in regard to the 
subject of infanticide; the defense in these cases often being that the woman 
was unconscious of the act of parturition. Unconscious delivery during the 
action of narcotic drugs and anesthetics, and in women in convulsions, stupor, 
coma, or moribund condition, is common, and women have been delivered 
unconsciously during profound sleep. f Unconscious delivery during hysteria 
is possible, but here as well as during sleep it is more than likely that the pains 
of the expulsive stage of labor would arouse the woman; this is especially 
true of primiparae, but every obstetrician is aware that in some women, par- 
ticularly multiparas with roomy pelves and relaxed soft parts, a very few and 
almost painless contractions of the uterus are sufficient to empty the uterus 
rapidly and easily. Perhaps the most frequent diseased condition in which 
a woman may be unconsciously delivered is the stupor, convulsions, or coma 
of puerperal eclampsia; as is well known, puerperal mania often follows this 
condition. 

Under the preceding conditions it is quite possible for a woman to be confined, 
to injure or even to kill her child, subsequently to be restored to consciousness, 
and to be perfectly truthful in her assertion of her entire ignorance of what had 
happened, and the clinical picture of puerperal albuminuria or eclampsia would 
sustain her statements. Again, the expulsion of the child has been mistaken 
for a strong desire on the part of the woman to empty her bowels ; this is a 
common defense set up for the charge of child murder. An intense desire to 
empty the lower bowel accompanies the expulsive stage of labor, and from 
our present knowledge of the subject, gleaned from many cases reported by 
competent observers, and from personal cases, a woman may be seized with 
this intense desire to defecate, hurriedly enter a water-closet or privy, and 

* Compare Kost: "Text-Book of Medical Jurisprudence," Cincinnati, 1885, p. 189. 
Goodell, W. : "Medical News," Phila., 1890, lviii, pp. 409-411. "Henke's Zeitschrift," 
vol. xliv, p. 172. Fischer, C: "Zeitschr. f. Wundartze u. Geburtsh.," Hegnach, 1SS7, 
xxxviii, pp. 264-268. "Ein forensicher Pseudo-Geburtsfall." 

t For cases of unconscious delivery during sleep compare Weill: "Gaz. Med. de 
Strasbourg," 1881, 1, x, p. 103; Case, M. W.: "American Journal Med. Sciences,"^ Phila.. 
1886, lv, p. 270; Samuelson, A.: "Brit. Med. Jour.," London, 1865, 11, p. 
"Journal des Sages-Femmes," Juillet 10, 1S91. 



VERTEX PRESENTATION. 501 

be absolutely ignorant of the act .of parturition until too late to save the expelled 
child from injury. _ Such accidents are possible and have happened. Before 
the claim of such an occurrence is accepted in a given case, a thorough inves- 
tigation should be made by the medical witness, including a vaginal examina- 
tion of the woman in question. 

I was hurriedly summoned one night to a case of this character, in 
which a servant in the family, a primipara, out of wedlock, and at or near 
term, mistook a nearly painless labor for a difficult defecation, and the child 
was born in the pan of the water-closet. The patient complained of lumbo- 
sacral pains and rectal pressure and denied any knowledge of the escape of 
liquor amnii. Attempted infanticide was of course suspected, but an investi- 
gation satisfied all that there was no premeditated infanticide. The child lived, 
and it and its mother were removed the same night to a hospital. 

In another case I was asked to see a woman in a New York tene- 
ment in which the patient, a multipara, was delivered precipitately on a fire- 
escape, in the act of leaning over the railing and exerting a good deal of strength 
in drawing a clothes-line loaded with clothes toward her; she was unaware 
of labor until the child, near term, struck the iron floor of the fire-escape. The 
child sustained contusions of the scalp and a depression of one parietal bone, 
but survived. 

In addition, we must bear in mind that while the woman may in a given 
case be unconscious of the expulsion of her child at the moment of delivery, 
yet she cannot remain ignorant of the fact that she has been delivered, if she 
be at the time conscious. 



XI. VERTEX PRESENTATION. 

Definition. — A vertex presentation is, strictly speaking, an occiput presenta- 
tion, the occiput being the region of the fetal head behind the posterior fontanelle 
including and surrounding the external occipital protuberances (Fig. 541). 
When this region forms the presenting part, there exists an occipital or so-called 
vertex presentation. This presentation affords the most natural posture for 
the fetus, the best opportunities for its favorable development, and at labor 
the best prognosis for both mother and child. 

Frequency. — The frequency of vertex presentations is 95 per cent, of all 
cases. Compare Presentations, page 471. 

Etiology. — See Presentations, page 473. 

Positions and Relative Frequency. — 

I. Left occipito-anterior, Occipito-laeva anterior, L. O. A., 70 per cent. 
II. Right occipito-anterior, Occipito-dextra anterior, R. O. A., 10 percent 

III. Right occipito-posterior, Occipito-dextra posterior, R. O. P., 17 percent 

IV. Left occipito-posterior, Occipito-lasva posterior, L. O. P., 3 per cent. 
In vertex presentations the first position obtains in 70 per cent, of cases; 

the second in 10 per cent.; the third in 17 percent.; and the fourth in 3 per 
cent . For the explanation of this relative frequency, compare Relative Frequency 
of Positions, page 476 (Fig. 584) 

Mechanism. — I. Left Occipito-anterior Position, L. O. A. (Fig. 593). — 
1. Flexion and Moulding oj the Head. — The sagittal suture in this position cor- 
responds to the right oblique of the pelvic inlet, or possibly to a diameter 
between this and the transverse. If head flexion is complete, the suboccipito- 



502 



PHYSIOLOGICAL LABOR 



bregmatic circumference, 13 inches (32.5 cm), is in relation with the circumfer- 
ence of the parturient inlet — the most favorable presentation (Fig. 593). 

Flexion. — Most authorities associate flexion of the head upon the body 
with this stage. Possibly flexion is rendered more complete at this time, but 
a study of frozen sections of pregnancy and elective versions before labor has 
convinced the author that flexion is complete, or nearly so, before the onset 
of labor. The normal attitude of the fetal ellipse during pregnancy is one of 
flexion of all its parts (page 470). The causes of flexion prior and subsequent 
to labor are: (1) The normal attitude of the fetal ellipse during pregnancy 
is one of flexion of all its parts. (2) This flexion of pregnancy is increased 
or completed during moulding and entrance of the head into the inlet because 
the sincipital pole of the head-lever is longer than the occipital pole; so that 
when the head encounters the resistance of thef parturient inlet the sincipital 
or long pole of the lever meets with greater resistance and ascends, forcing 

the chin nearer the sternum, 

2 " 4% and thus emphasizing or 

completing primary or gesta- 
tional flexion (see page 470). 
The fetal head and body may 
be regarded as consisting of 
two bars which are connect- 
ed. The bar which repre- 
sents the head is joined to 
the one representing the 
spinal column not by its 
middle, but at a point nearer 
one extremity (Fig. 585). It 
will be seen that an equal 
force brought to bear on this 
mechanism will cause greater 
flexion of the longer bar, 
which stands for the part of 
the fetal skull which is an- 
terior to the spinal column — 
namely, the sincipital pole. 
(3) Adaptation or accommo- 
dation. A tendency of the 
fetal ellipse, and particularly the cephalic ellipsoid, to adjust itself to the shape 
of the upper part of the parturient canal is another factor in determining head 
flexion. If for any reason flexion be not complete, then possibly a circumfer- 
ence as great as the occipito-frontal (13 J inches — 34.5 cm.) will be in relation 
with the circle of resistance of the parturient inlet. Complete antero-posterior 
flexion of the head is normally present at this time, and opinions differ as to the 
occurrence of lateral flexion or inclination. A lateral inclination of the fetal 
head toward the maternal sacrum bringing the sagittal suture nearer to the pro- 
montory than to the symphysis is termed Naegele's obliquity, or asynclitism 
(P a g e 57 0- When the head descends with its planes parallel with the pelvic 
planes, a synclitic condition of the head is present. With normal pelves and 
fetuses the synclitic engagement of the head exists (Kiineke); in labor with 
deformed pelves, especially with flattened pelves, Naegele's obliquity is some- 
times found (see Pelvic Deformity, pages 611 and 612). By Solayres's obliquity 
(Fig. 593) is understood the entrance of the sagittal suture into the pelvic inlet 




Fig. 584. — Diagram showing the Relative Fre 

QUENCY OF THE POSITIONS OF VERTEX PrESENTA 
TION. 



VERTEX PRESENTATION. 



503 



in an oblique diameter. Roederer's obliquity is extreme flexion of the chin on 
the sternum (page 551). 

Moulding. — In most labors adaptation of the skull to the pelvis is brought 
about by certain movements of the bones of the cranial vault upon one another. 
Moulding is an important and possibly an essential factor in the mechanism 
of labor, since it prepares the head for a ready engagement and descent, and 
the change in the shape of the head lowers the dip of the occipital pole of the 
head lever in the pelvis, thus favoring and rendering more positive anterior rota- 
tion of the occiput later on. Post-partum measurements show that the greatest 
reductions in the diameters take 
place in the transverse ones, which 
are often lessened by twice the 
width of the sagittal and frontal 
sutures. The fontanelles also assist 
in the compression of the head, so 
that the transverse diameters are 
often diminished from § to ^ inch 
(1.5 to 2 cm.), and a corresponding 
elongation occurs in the sagittal 
diameters, but it can be shown by 
a study of many fetal skulls that 
the changes in shape of the skull 
in vertex presentations due to 
moulding consist not so much in 
actual measurable changes in the 
length of the head as in the flatten- 
ing of the region about the brow 
and anterior fontanelle, an arching 
and greater prominence of the pre- 
senting part of the parietal bone, 
and, in prolonged labors, a more 
vertical position of the squamous 
portion of the occipital bone. A 
summary of the disposition of the 
bones of the skull due to moulding 
in vertex presentation is as fol- 
lows: (1) The anterior or present- 
ing parietal bone is the lowest pre- 
senting part, and it overlaps not 
only its fellow but also the frontal 
and occipital bones. Thus, in the 
two left positions of the vertex the 

left or posterior parietal bone is overridden by the right ; and in the two right 
positions the right or posterior parietal bone is overlapped by the left (Figs. 589 
to 592). (2) The half of the frontal bone which is posterior and toward the 
sacrum is overlapped by its neighboring bones and is slightly flattened by the 
pressure of the promontory (3) Again the anterior or lowest parietal bone 
bulges more and becomes more prominent, while the posterior or higher parietal 
bone, which is against the sacrum, is forced toward the frontal bone and relatively 
flattened. Thus the halves of the skull are somewhat asymmetrical (Figs. 589 
to 592). (4) The portion of the head which is lowest and constitutes the pre- 
senting part is often forced out into a point and forms the apex of a cone, 




Fig. 5S5. — Diagram showing the Relation 
of the Lever-like Action of the Head 
to the Fetal Axis. 



504 



PHYSIOLOGICAL LABOR. 



MOULDING IN VERTEX PRESENTATION. 
ANTERIOR POSITIONS. 




V 




Fig. 586. — Before Moulding. 



X 




Moderate Moulding. 




Fig 



Excessive Moulding. 



the base of which corresponds to that 
plane which passes through the par- 
turient canal first. Thus, in the L. 
O. A. position the suboccipito-breg- 
ma/tic circumference or plane forms 
the base of a cone, the apex of which 
is the posterior superior angle of the 
right parietal bone. This explains 
the situation of the caput succeda- 
neum and of a cephalhematoma. In 
ordinary cases deformity from mould- 
ing disappears in one or two days, and 
in the more pronounced cases in two 
to four days. In cases of contracted 
pelves with excessive moulding of the 
head, permanent deformity may re- 
sult which perhaps can be positively 
determined only by taking a cast of 
the head, as measurements are mis- 
leading and unreliable. 

The Caput Succedaneum. — The 
change in the shape of the head pro- 
duced by moulding is still further 
modified by a swelling on that portion 
of the presenting part which is least 
subjected to pressure from the canal, 
due to venous hyperemia and oedema, 
and termed the caput succedaneum 
(See Part IX). In the L. 0. A. posi- 
tion the caput forms upon the poste- 
rior superior angle of the right parie- 
tal bone, encroaching somewhat upon 
the small fontanelle and occipital bone 
(Fig. 594). Wrinkling of the scalp 
usually precedes the formation of the 
tumor, and is indicative of commenc- 
ing pressure. The scalp tumor may 
form within the bag of membranes 
before their rupture ; after rupture of 
the membranes while the cervix is 
only partly dilated; and, thirdly, at 
the vaginal outlet after the head 
reaches the pelvic brim. In the first 
two instances the caput is usually 
small and of little practical impor- 
tance, but at the vaginal outlet, where 
it usually forms, it may attain con- 
siderable size, and may enable one 
after delivery to diagnose the position 
the head occupied within the birth 
canal. While it is true that in normal 
labor the caput most often forms 



VERTEX PRESENTATION. 



505 



within the birth canal, still in con- 
tracted pelves, by reason of the re- 
sistance of the pelvic inlet, an enor- 
mous scalp tumor ma}* form before 
the head enters the bony pelvis. 
Upon the sinciput the caput is usu- 
ally larger than when situated upon 
the occiput, partly by reason of the 
greater laxity of the tissues in the 
former situation, and partly be- 
cause of the longer duration of 
labor when the sinciput is directed 
to the front. In size the diameter 
may vary from one to two inches 
(2.5 to 5 cm.) or more. In left occi- 
pitoanterior positions the caput 
forms upon the superior posterior 
angle of the right parietal bone, 
overlapping somewhat the small 
fontanelle and occipital bone; in 
right occipito-anterior positions, 
upon the corresponding point of the 
left parietal bone ; in right occipito- 
posterior positions the tumor de- 
velops upon the anterior superior 
angle of the left parietal bone, 
sometimes overlapping the frontal 
suture; in left occipito-posterior 
positions we find the caput upon 
the anterior superior angle of the 
right parietal bone, also often over- 
lapping the frontal suture. In in- 
stances of a moderately rapid labor 
up to the time the head reaches the 
pelvic floor, and in instances in 
which the internal rotation of the 
head has been complete and the 
head is detained for a long period 
at the vaginal outlet, a large caput 
succedaneum often forms directly 
in the median line over the sagittal 
suture, and thus possibly obscures 
the diagnosis. 

2. Engagement and Descent of 
the Head (Fig. 593). — It must be 
remembered that flexion, engage- 
ment, and descent of the head are 
often completed before labor actu- 
ally sets in, this being specially true 
of primigravidas (see Engagement 
and Descent, page 492). In these 
cases of ante-partum engagement 



MOULDING IN VERTEX PRESENTATION, 
(AUTHOR'S COLLECTION OF SKULLS.) 




Fig. 589. — -Left Position. Posterior View 

— — - 





Fig. 590. — Left Position. Anterior View. 




Fig. 591. — Ru 



jfpi 



Posterior View. 



I 




Fig. 592. — Right Position. Anterior View. 



506 



PHYSIOLOGICAL LABOR. 



VERTEX PRESENTATION. 

FIRST VERTEX POSITION. 

LEFT OCCIPITOANTERIOR, L. O. A, 



v: 




v 

i 

Fig. 



593- 



■At Pelvic Inlet. 




Fig. 



594- 



•Right Parietal Bone in the 
Cervix. 



^ 




Fig. 



595- — Head 

FORE 



at Pelvic 
Rotation. 



Floor be- 



and descent, head-flexion is completed 
or emphasized in the transit of the head 
through the cervix. Exceptionally be- 
cause of a small head, or a softened and 
completely dilated cervix, — the latter in 
multiparas, — the ring of the cervix does 
not enter as a factor into the causation 
of flexion. In exceptional cases only is 
Naegele's obliquity present, and usually 
the head enters the pelvis in the axis of 
the inlet with the biparietal diameter 
parallel with the plane of the inlet, and 
this relation of the head to the successive 
planes of the pelvis is maintained until 
the pelvic floor is reached. Engagement 
and descent go hand-in-hand, and the 
ease and promptness with which the 
latter are accomplished will depend upon 
the resistance encountered at the barrier 
of the cervix and in the walls of the pelvis 
and vagina. 

3. Anterior Rotation of the Occiput 
(Figs. 595 and 596). — Descent continues 
until the most dependent portion of the 
presenting part — the occiput — reaches 
the pelvic floor. For reasons already 
set forth (page 493), anterior rotation of 
the occiput occurs so that it turns for- 
ward under the pubic arch, and the sagit- 
tal suture occupies very nearly the an- 
tero-posterior diameter of the bony 
pelvic outlet (Fig. 597). Excessive rota- 
tion: We occasionally see excessive in- 
ternal rotation of the head, by which is 
meant that the sagittal suture rotates 
from one oblique pelvic diameter past 
the conjugate and into the opposite ob- 
lique. This is probably in consequence 
of excessive rotation of the trunk, due 




Fig. 596.— Head at Pelvic Floor after 
Anterior Rotation. 




Fig. 597. — In "the Vulva, with Incom- 
plete Anterior Rotation. — {From a 
photograph.) 



VERTEX PRESENTATION. 



507 



SECOND VERTEX POSITION. 
Right Occipitoanterior, r. O. a, 




Fig. 598. — At Pelvic Inlet. 




Fig. 



599. — -Left Parietal Bone in 
Cervix. 




Fig. 600. — Head at the Pelvic Floor 
before Anterior Rotation. 



to strong uterine contractions compress- 
ing the fetal back and turning it toward 
the front and opposite side. In my sixty- 
nine observations in primiparae, and 
seventy-one in multiparas, excessive ro- 
tation of the head from one oblique 
diameter to the other occurred in but 
one instance — a primipara.* 

4. Extension and Expulsion of the 
Head (Figs. 581 and 582). — Rotation 
being complete, there comes a time 
when, the occiput having passed under 
the subpubic ligament and being par- 
tially born, the shoulders attempt to 
enter the pelvis with the head; and as 
under ordinary circumstances there is 
not sufficient room for both, the head 
escapes from the vulva by a movement 
of extension. This is not strictly true, 
for repeated observations show that 
part of the head, including the occiput, 
is born before the chin leaves the ster- 
num, a fact we must always remember 
in our attempts at perineal protection 
and forceps delivery (Fig. 580). This 
escape of the head is caused by the force 
of uterine contraction acting through the 
spinal column and by the contraction of 
the muscles that go to make up the pelvic 
floor; and we see the beautiful provision 
of nature that has caused only the 
smallest circumference — namely, the 
suboccipito-bregmatic, 13 inches (33 
cm.) — to be passed through the birth 
canal ; and even at the vulva, the occiput 
having been born first, all the circumfer- 
ences of the fetal head that pass in suc- 




•»-A 




Fig. 601. — Head at the Pelvic Floor 
before Anterior Rotation. 



Fig. 602. — Head Expulsion after Ante- 
rior Rotation. — {From a photograph.) 

* Edgar: "The Mechanism of Labor; Some Experimental and Clinical Observations,' 
'Amer. Journ. Obstet.," vol. xxvin, No. 4, 1893. 



508 



PHYSIOLOGICAL LABOR. 



cession through the vulval opening are measured not from the occipital protuber- 
ance, which is already born, but from a point midway between it and the foramen 
magnum, and are consequently the smallest or the suboccipital circumference 

(Fig- 58i)- 

5. Rotation of the Trunk and Restitution of the Head. — The right or lower 

shoulder rotates to the pubis and the 



THIRD VERTEX POSITION. 
Right Occipito-Posterior, R. O. p. 



-^7*"\ 




Fig. 603.— At the Pelvic Inlet. 



face looks toward the right thigh of the 
mother. (See Mechanism, page 496.) 

6. Expulsion of the Trunk. — We have 
now followed the bisacromial diameter 
into the antero-posterior diameter of 
the pelvic outlet. The involuntary and 
voluntary forces direct the shoulders 
into the parturient outlet. Shoulder 
delivery: The right or anterior shoulder, 
whether it does or does not appear first 
under the arch of .the pubis, is usually 
detained at this point, and the posterior 
or left or perineal shoulder, with arm 
and forearm, are propelled over the edge 
of the perineum and born, their escape 
being followed by the delivery of the 
right or pubic shoulder and arm (Fig. 
628). With the birth of the shoul- 
ders the arms, forearms, and hands are 
usually found flexed upon the child's 
1-Tffrnmi chest, as they are found in the normal 

gf- attitude (see page 470). The shoulders 

/ / - I I having been delivered, the body usu- 

ally follows immediately after. Some 
'^| obstetricians would speak of a stage of 

rotation of the buttocks, but there is 
every reason to believe that when the 
shoulders rotate the buttocks rotate 
with them, in ordinary cases, and con- 
sequently there is little or no torsion 
of the body, but the buttocks come 
down and are expelled in the antero- 
posterior diameter of the outlet in prac- 
tically the same way as are the shoulders. 
II. Right Occipito-anterior Posi- 
tion, R. O. A. (Fig. 598). — (1) Flexion 
and moulding of the head: This stage in 
the mechanism is the same as in the L. 
O. A. position, except that the caput 
forms upon the posterior superior angle 
of the left parietal bene and the shape of the head and the overlapping 
of the bones differ (Fig. 599). (2) Engagement and descent: The sagittal 
suture enters the left oblique diameter of the pelvic inlet and descent occurs 
as before until the pelvic floor is reached (Fig. 600). (3) Anterior rotation of 
the occiput: This occurs, for reasons already stated, from right to left instead 
of from left to right as in the L. 0. A. position (Fig. 600). (4) Extension and 



Fig. 



604. — Left Parietal Bone in the 
Cervix. 



^X" r > 



^sf. 




Fig. 



605. — Vertex at the Pelvic Floor 
before Anterior Rotation. 



VERTEX PRESENTATION. 



509 



(6) Expulsion of the trunk is the 
THIRD VERTEX POSITION.— (Cont.) 




Fig. 606. — Vertex at the Pelvic^Floor 
before Anterior Rotation. 



expulsion of the head are the same as in the L. O. A. position. (5) Rotation 
of the trunk: The bisacromial diameter of the shoulders enters the right ob- 
lique diameter of the pelvic inlet and the rotation of the trunk causes the left 
shoulder to come under the pubic arch 
same as in the L. O. A. position, as 
regards anterior and posterior shoulder 
delivery (Fig. 628). 

III. Right Occipito-posterior 
Position, R. O. P. (Fig. 603). — 1. Flex- 
ion and Moulding of the Head. — This 
stage is the same as in the R. O. A. 
position, except that the flexion is liable 
to be imperfect. The caput succedaneum 
develops upon the anterior superior 
angle of the left parietal bone, some- 
times overlapping the frontal suture 
(Fig. 604), and the shape of the head 
and the overlapping of the bones differ 
(Figs. 591 and 592). 

2. Engagement and Descent of the 
Head. — The suboccipito-bregmatic di- 
ameter in this position enters the inlet 
in its right oblique diameter. Following 
engagement we have descent, in some 
cases until the pelvic floor is reached, and 
in others anterior rotation of the vertex 
occurs before the pelvic floor is reached. 
In these latter instances there is every 
reason to believe that it is the resistance 
of the posterior wall of the uterus or of 
the recto-vaginal septum that deter- 
mines this early rotation (Fig. 537). 

3. Rotation of the Occiput. — When 
once the vertex has reached the pelvic 
floor, the case may terminate in one of 
four ways, and, in order of frequency, 
they are as follows: First, complete an- 
terior rotation of the occiput about the 
right half of the pelvis until the pubis 
is reached; second, posterior rotation of 
the vertex into the hollow of the sacrum 
and birth of the head with the occiput 
to the rear by extension over the peri- 
neum; third, posterior rotation and im- 
paction; and, fourth, the conversion of the vertex presentation into one of 
face presentation; and although this latter termination is extremely rare, 
some instances of it are on record, and we are compelled to recognize its possi- 
bility (Fig. 545). (1) Anterior rotation: It is unnecessary to describe the first 
method of termination; the same principles apply here as in the first and second 
positions. The greater resistance of the posterior segment of the pelvic floor 
causes the occiput to be deflected in the direction of least resistance — namely, 
to the vulval orifice (Fig. 606). (2) Posterior rotation and birth of the occiput 




Fig. 607. — Restitution of the Head 
after Anterior Rotation and Ex- 
pulsion. 




Fig. 608. — Delivery of the Head after 
Posterior Rotation of the Occiput. 



510 



PHYSIOLOGICAL LABOR. 



FOURTH VERTEX POSITION. 
LEFT OCCIPITO-POSTERIOR, L. O. P. 




Fig. 609. — At Pelvic Inlet. 



over the perineum: Instances occur, however, in which from some cause, as roomi- 
ness of the pelvis, smallness of the child, want of rigidity of pelvic floor from 
numerous labors, or other causes, — distention of the floor by the passage of the 
first twin, incomplete flexion of the head, permitting the sinciput to be as low as 
or lower than the occiput , — anterior rotation fails. Most authorities state this to 

be a rare condition, yet according to 
Naegele's statistics it occurred once in 
73 cases of labor. In 2200 labors I 
found persistent occipito-posterior posi- 
tion to occur in 89 cases of labor, or 
4.04 per cent. Should anterior rotation 
fail and the occiput remain in the pos- 
terior half of .the pelvis, it is possible 
under certain conditions for the occiput 
to follow the posterior wall of the par- 
turient canal and to be born by exten- 
sion over the edge of the perineum. 
Labor then is almost always prolonged, 
and in some instances impossible as the 
result of impaction (Fig. 608). The cause 
of the prolongation of the labor under 
such circumstances was first pointed out 
by P. Dubois, and is readily understood. 
The back of a child's neck (Fig. 541) is 
not much over 3 inches (7.5 cm.) in 
length; the posterior wall of the par- 
turient canal, from the promontory of 
the sacrum to the edge of the perineum 
(Fig. 523), is in the neighborhood of ten 
inches (25 cm.), counting five inches 
from the promontory to the tip of the 
coccyx and five more from this point to 
the edge of the distended pelvic floor. 
If an anterior position of the vertex 
obtains, the birth of the head is readily 
and easily accomplished; for the two 
inches of the back of the neck without 
any difficulty pass over the if inches 
(4 cm.) of the anterior pelvic wall meas- 
ured at the symphysis, and the head is 
born before the shoulders necessarily 
enter the pelvic inlet. For the head to 
be born in an occipito-posterior posi- 
tion we may hope for no break in the 
straight and rigid mass that the fetus 
represents, until the head together with 
the neck has traversed the ten inches 
of the posterior pelvic and perineal walls, and the head is finally permitted to 
be born over the perineum. Delivery under such circumstances is certainly 
possible by the natural forces, for after an exceedingly tedious labor and extreme 
flexion of the head on the sternum, and the occiput distending the pelvic floor for 
several hours, finally with tremendous bearing-down efforts on the part of the 




Fig. 



610. — Right Parietal Bone in the 
Cervix. 





Fig. 611. — Vertex at the Pelvic Floor 
before Anterior Rotation of the 
Occiput. 



VERTEX PRESENTATION. 



511 



FOURTH VERTEX POSITION.— (Cont.) 




Fig. 612. — Vertex at the Pelvic Floor 
before Anterior Rotation of the 
Occiput. 



parturient woman, the occiput is enabled to climb up, as it were, over the edge 
of the perineum, the forehead and face appear at the pubes, and the perineum 
slipping by the occiput and along the neck, extension completes the birth of the 
head. (3) Posterior rotation and impaction: Unfortunately we occasionally meet 
with instances in which anterior rotation of the occiput or spontaneous delivery 
of the occiput to the rear both fail to occur. And if we have added an impaction 
and swelling of the shoulders that have 
partially entered the pelvic cavity, we 
have one of the tragedies of midwifery 
practice. Given a normal-sized fetus, a 
pelvis of ordinary dimensions, perhaps a 
primipara with rigid soft parts, and the 
cause of impaction of those cases of 
occipito-posterior position that have 
been improperly treated in the earl)' 
second stage of labor is easily under- 
stood. The occiput passes into the hol- 
low of the sacrum, reaches the coccyx 
perhaps, but still is several inches (5 
inches) from the edge of the perineum. 
Under the circumstances the body of 
the child must enter the pelvic cavity 
with the head in order to allow of the 
occiput's reaching the edge of the peri- 
neum. We have impaction then because 
the dorso-sternal diameter, 3! inches 
(9.5 cm.) (Fig. 551), is added to the 
fronto-mental diameter, 3^ inches (8.25 
cm.) (Fig. 540), giving an anteropos- 
terior diameter of the presenting fetal 
mass of 7 inches (17.78 cm.) that the 
uterine forces are attempting to drive 
through a pelvis the average diameter 
of which is usually not more than 4} 
inches (12 cm.) (Fig. 516). And this is 
not all; the length of the fetal ellipse 
when the child is in normal attitude is 
half the length of the entire fetus — 
namely, about 11 inches (27.5 cm.); 
consequently when the occiput has 
come to the edge of the perineum 
the breech of the child has practically 
entered the inlet of the pelvis, and the 
uterus under such circumstances cannot 
but act at a disadvantage. We can 
readily see, then, what either spon- 
taneous or artificial birth of the fetus means to the mother — almost invariably 
a partial or complete loss of her perineal structures, or uterine inertia and ex- 
haustion (Fig. 608). (4) Conversion into a face presentation: The fourth man- 
ner in which this posterior position may terminate is for the occiput in some 
way to become arrested in its course, and then, the chin leaving the ster- 
num, rotation on a biparietal diameter takes place, the head, as it were, turns 




Fig. 613. — Expulsion of the Head after 
Anterior Rotation of the Occiput. 



Fig. 




Restitution of the Head. 



512 



PHYSIOLOGICAL LABOR. 






^ 



a somersault, becomes extended within the pelvic cavity, and we have resulting 
a face presentation of the mento-anterior variety. This is of rare occurrence 
spontaneously. A few manual conversions of an occipito-posterior position into 
a face presentation within the pelvis have been reported 

4. Expulsion of the Head. — If, as happens in all but 1.5 per cent, of cases, 
anterior rotation of the occiput about the right half of the pelvis to the pubis 
occurs, the head delivery is the same as in the R. O. A. position (Fig. 602). 

5. Rotation of the Trunk. — The shoulders enter the pelvis with the bisacro- 
mial diameter in the left oblique pelvic diameter, and the left anterior or lowest 
shoulder naturally rotates to the pubis. 

6. Expulsion of the Trunk. — After shoulder rotation this is' the same as 
in the R. O. A. position. 

IV. Left Occipito-posterior Position, L. O. P. (Fig. 609). — (1) Flexion 
and moulding of the head: This stage is the same as in the L. O. A. position, 
except that the flexion is liable to be imperfect, the caput succedaneum develops 

upon the anterior superior angle 
of the right parietal bone, often 
overlapping the frontal suture 
(Fig. 610), and the shape of the 
head and overlapping of the 
bones differ somewhat (Figs. 589 
and 590). (2) Engagement and 
descent of the • head: The sub- 
occipito-bregmatic diameter in 
this position enters the left ob- 
lique diameter of the inlet (Fig. 
609). Descent now occurs as in 
the L. 0. A. position (page 505). 
(3) Rotation of the occiput: The 
same general principles govern 
the further progress as in the R. 
O. P. position, except that back- 
ward rotation in the 1 . 5 per cent, 
would occur from left to right, 
and the anterior rotation which 
usually occurs takes place around 
the left side of the pelvis to the 
pubis (Figs. 611 and 612). Delivery or impaction in occipito-posterior cases is 
the' same as in the R. O. P. position (page 495). (4) Expulsion of the head: If, 
as happens in all but 1.5 per cent, of cases, anterior rotation of the occiput about 
the left half of the pelvis to the pubis occurs, the head delivery is the same as in 
the L. O. A. position (Fig. 597). (5) Rotation of the trunk: The bisacromial 
diameter enters the right oblique diameter of the inlet, and the right or anterior 
or lowest shoulder naturally rotates to the pubis (Fig. 583). (6) Expulsion of 
the trunk: After shoulder rotation this is the same as in the L. O. A. position 
(Figs. 628 and 629). 

Diagnosis. — One may be required to make the diagnosis of vertex presenta- 
tion (1) during pregnancy, (2) during labor, (3) after labor has been completed. 
t. During Pregnancy (see table on page 514).— The diagnosis of vertex 
presentation during pregnancy before the os is sufficiently dilated to permit 
of distinguishing sutures or fontanelles, or the character of the presenting part, 
is made by external or abdominal palpation (see page 514). 




Fig. 615. — The Palpation of the Anterior or 
Lowest Ear of the Fetus as a Means of 
Positive Diagnosis of the Position. 



VERTEX PRESENTATION. 513 

2. During Labor. — Abdominal palpation may be carried out as well during 
labor between the pains. When labor has advanced far enough for us to palpate 
the vault of the skull, the diagnosis of vertex positions is made from the position 
and character of the fontanelles and sutures which we can palpate. Vertex 
presentations are recognized by the characteristic sensation of a hard and globular 
head, which soon becomes familiar to the student. The diagnosis of the position 
must be made by mapping out the sutures and fontanelles. This is apt to puzzle 
the beginner, and is sometimes difficult for the experienced obstetrician, and can 
be learned only by practice upon the manikin and at the bedside (see Figs. 594 and 
599). On entering the os uteri the finger usually finds first the anterior parietal 
bone, and behind this the sagittal suture. Taking this suture as the chief land- 
mark, and remembering that it has a fontanelle at each end, the examining finger 
undertakes to find these fontanelles or one of them. Folio wing the sagittal suture 
downward and forward, the small (occipital) fontanelle is found toward the 
mother's left if the position be an L. 0. A., or toward her right if it be an R. O. 
A. The beginner should not forget that the small fontanelle, as soon as the 
uterine contractions commence to force the head into the pelvic brim, is not an 
opening, but only an angle formed by the posterior borders of the parietal 
bones and the anterior edge of the occipital. Following the sagittal suture 
back from the posterior fontanelle, the finger may reach the large, soft 
anterior fontanelle, and the student should not be satisfied with his diagnosis 
unless he has recognized both fontanelles. If the head is well flexed, the pos- 
terior fontanelle may be the first thing encountered by the finger, and the ante- 
rior fontanelle may be so far back that to reach it is difficult. Important points 
for the student to remember are that from the posterior fontanelle run three 
sutures, from the anterior fontanelle, four; that a posterior fontanelle easily 
reached denotes good flexion of the head, and that an anterior fontanelle easily 
reached denotes small size of head, incomplete flexion, bregma presentation, or 
a posterior position of the occiput. An exact diagnosis by sutures and fon- 
tanelles is by no means essential in every apparently normal case before rup- 
ture of the membranes, and to insist upon it is to expose the patient to the 
danger of premature rupture of the membranes and septic infection. Palpation 
of the anterior or lower ear is a valuable diagnostic sign (Fig. 615) 

3. After Labor. — After labor is completed we are sometimes called upon, 
for medico-legal purposes, to express an opinion regarding the presentation 
in which the child was born. We usually rely on two points in making the 
diagnosis of presentation at this time. First, the shape of the child's head; and, 
second, the position of the caput succedaneum. When labor has been rapid, when 
there has been no caput, and when little or no moulding has occurred, there is 
nothing by which we may be enabled to express a positive opinion, and there is 
nothing in the genital canal of the woman to aid us in making our diagnosis. 

Prognosis. — Vertex presentation offers the best prognosis for both mother 
and child, but it varies slightly with the position, — the anterior being more favor- 
able than the posterior, since in the latter cases the labors are generally longer and 
more difficult, while the forceps is necessary about once in seven cases. The soft 
parts are more frequently torn. The maternal mortality is less than 1 per cent, 
when the case is intelligently managed. The fetal mortality is 5 per cent, in ante- 
rior vertex positions, and is increased to over 9 per cent, in posterior positions. 
33 



514 



PHYSIOLOGICAL LABOR. 
DIAGNOSIS OF VERTEX POSITIONS. 





Position of Fetus. 


Position of Fetal 
Heart-sounds. 


Left occipitoanterior, Occiput to left acetabulum, forehead to 
L. 0. A. right sacro-iliac joint; back to left; 
extremities to right, above. 


Below and to the left of 
umbilicus. 


Right occipitoante- 
rior, R. 0. A. 


Occiput to right acetabulum, forehead 
to left sacro-iliac joint; back to right; 
extremities to left, above. 


Near median line, below 
umbilicus. 


Right occipito-poste- 
rior, R. 0. P. 


Occiput to right sacro-iliac joint, fore- 
head to left acetabulum; back in right 
flank; extremities to left, anteriorly. 


In right flank, below a 
transverse line through 
umbilicus. 


Left occipito-poste- 
rior, L. 0. P. 


Occiput to left sacro-iliac joint, forehead 
to right acetabulum; back in left 
flank; extremities to right, anteriorly. 


In left flank, below a 
transverse line through 
umbilicus. 



XII. THE MANAGEMENT OF LABOR 

Imitation of nature is the key to the management of normal labor. ' By 
management is not meant interference, but watchful observation. A proper 
understanding of this fundamental principle will serve to do away with 
much meddlesome and injurious practice. In fact, it is not too much to say- 
that in normal cases the object of the accoucheur is to find out, not how much, 
but how little interference is justifiable. The desire of the student to see and 
to study abnormal cases should be restrained until he has become thoroughly 
familiar with the phenomena and natural course of normal labor. It is scarcely 
an exaggeration to state that the greater proportion of the morbidity if not 
the mortality of child-birth is due to the careless and unskilful management 
of normal labor. Meddlesome midwifery, sins of commission, may be dangerous ; 
it is equally so in obstetrics to adhere too closely to the modern dictum, that 
there shall be no interference without a positive indication. Let him or her 
beware who adopts the latter course and follows it without a thorough famil- 
iarity with the physiological processes of normal labor and the many and varied 
dangers which may suddenly and unexpectedly arise during child-birth. Imita- 
tion and a watchful expectancy, not a blind, unreasoning trust in the processes 
and powers of nature, should guide us in the management of labor. What 
apparently begin as the simplest labors will often subsequently demand active 
interference on the part of the attendant. The whole process of labor, properly 
considered, is a conservative process the tendency of which is to prevent sepsis, 
and it should be our aim not to thwart this process or supplant it by methods 
of art, but to follow and aid it, interfering only when, for one reason or another, 
the resources of nature prove insufficient. Nature's processes in labor are 
from within outward. The fetus starts on its journey through the parturient 
canal from the sterile uterine cavity, passes through the aseptic cervix, continues 
on its way through the vagina, a tube which while often containing bacteria, 



THE MANAGEMENT OF LABOR. 515 

even of those species which are sometimes pathogenic, may still be regarded as 
sterile in the majority of cases, and only at the point of final expulsion comes 
in contact with a surely septic surface, at a time when such contact can do no 
harm. In other words, the fetus passes from the clean to the relatively clean, 
and finally to the unclean. Moreover, during and after the journey of the fetus 
through the birth-canal nature has provided additional safeguards against 
infection, notably the physiological increase of the vaginal mucus, which while 
its germicidal power has doubtless been greatly overestimated may at least be 
regarded as in most cases unfavorable to the multiplication of bacteria, and 
which attends the normal progress of the first and second stages of labor; the 
flushing of the canal from within outward by the aseptic, saline liquor amnii 
at the end of the first stage ; by a second flushing of the canal by a rush of aseptic 
saline blood and liquor amnii at the termination of the second stage ; at the 
termination of the third stage the cleansing process is completed by the out- 
ward passage of the placental mass and the subsequent flow of blood. Then 
follow quickly the reparative processes of nature to close the open blood-vessels 
and lymphatics. While, as we thus see, all nature's processes are from within 
outward and conservative, — from the sterile toward the septic, — manipula- 
tions on the part of the obstetrician must necessarily be from without inward — 
from the unclean toward the clean. It is also probable that the microorganisms 
of the external genitals have an intrinsic tendency to migrate to the vagina, 
and to invade the puerperal uterus, and even the uterus in labor; and that they 
are able to prevail at times even in the face of the conservative forces just 
enumerated. Hence the importance of non-interference except in the presence 
of a positive indication. 

Prophylaxis. — While in the management of pregnancy we can, as a rule, 
act only indirectly as far as gynecological prophylaxis is concerned, we can in 
the management of labor do a great deal which is of positive and immeasurable 
benefit to the patient in preventing subsequent serious and perhaps lifelong 
disability. 

Limiting the Duration of Labor. — That a labor prolonged beyond the limits 
of safety is of itself the cause of subsequent local trouble is well known. This 
statement is applicable to all kinds of abnormal labor, but finds its best appli- 
cation in cases in which local sloughing of the maternal parts (leading sometimes 
to vesico-vaginal fistula) is caused by prolonged pressure of the fetal head. Mater- 
nal lesions may be the result not only of the premature or unskilful use of the 
forceps, but also of undue delay in its use. To lay down exact rules, as some 
have attempted to do, as to the time which should be allowed to elapse before 
the application of the forceps without reference to the individual case, is wrong. 
Many other circumstances must guide us here. But it is safe to say that when 
with good uterine contractions the head remains stationary, the danger of 
injury to the maternal soft parts becomes an important factor. A similar 
danger also arises from too prolonged efforts to retard the passage of the head 
through the vaginal outlet in order to prevent laceration of the perineum. 
I refer here not only to the dangers arising from prolonged pressure, but also 
to permanent relaxation of the muscular structures of the pelvic floor, with 
resulting disability. 

Prompt Surgical Treatment of Traumatism. — It should be the aim of the 
obstetrician to leave his patient in at least as good condition as that in which 
he finds her, and no man should attempt the care of the lying-in patient who 
does not understand the ultimate results of the more common lesions of the 
genital tract which may accompany the parturient act, and the methods 



516 PHYSIOLOGICAL LABOR. 

of their repair. Not long ago, when trachelorrhaphy was a very common 
operation, and when the importance of cervical lacerations with reference not 
only to the etiology of cancer but of various lesser troubles was overrate d r 
the immediate suture of cervical lacerations was advocated in many quarters. 
With the advent of more correct views, however, the majority of obstetricians 
do not favor the immediate repair of cervical lacerations unless required by 
severe hemorrhage. The danger of sepsis is by no means inconsiderable. 
The importance of the immediate repair of all lacerations which endanger 
the muscular structure of the pelvic floor is now generally recognized. 

Asepsis. — Most important of all in connection with prophylaxis during labor 
is rigid attention to asepsis and antisepsis. The importance of septic infection 
as a factor in the production of uterine and pelvic disease is too evident to need 
comment. One fact, however, I desire to emphasize: viz., that what is called 
antiseptic midwifery, while it has enormously decreased the mortality from 
puerperal infection, has by no means had a corresponding effect upon the mor- 
bidity. We are too prone to consider only mortality in our results and to 
pass over entirely the question of morbidity. Even to-day the influences upon 
morbidity, the ultimate consequences of a mild puerperal process, are too 
apt to pass unrecognized by the obstetrician, and the case passes into the hands 
of the gynecologist for the cure of chronic uterine and peri-uterine inflammation, 
which had its origin in an unnecessary, if not careless, vaginal examination. 
We hear much of a lowered mortality, and little or nothing of a reduced mor- 
bidity. 

Preliminary Preparations. — (i) The obstetric outfit. (2) Mother's outfit. 
(3) Baby's outfit. (4) Physician's obstetric bag. (5) The obstetric nurse. (6) 
The lying-in room. (7) The labor bed. (8) Articles to be in readiness at time 
of labor. 

The Obstetric Outfit. — Shall the obstetric outfit be prepared by the 
patient or nurse, or shall it be procured already prepared from some dealer 
in surgical dressings? A further question naturally suggests itself — namely, 
Of what does the obstetric outfit to-day consist? Aside from the mother's 
outfit, meaning the clothes she will need during her lying-in period, and the 
"baby's outfit," including, if possible, a "baby's basket," the obstetric outfit 
should include at least the following articles: (1) A douche pan, preferably 
square and of enamel or agate-ware. (2) Two ordinary rubber blankets, or 
two pieces of rubber sheeting, one one yard square and the other two yards 
square. (3) Three or four dozen soft napkins for vulval dressings, or the same 
number of vulval pads from a surgical-dressing dealer. (4) One or two pounds 
of sterilized absorbent cotton, or twenty-five yards of cheese-cloth or sterilized 
gauze, for sponging. (5) Six abdominal binders of soft muslin or mull, eighteen 
inches wide and preferably made to fit the figure at the sixth month of gestation. 
(6) Two hand-brushes. (7) Some old linen for the baby's eyes and mouth. 
(8) Four ounces of tincture of green soap. (9) Bottle of sublimate tablets. 
(10) Seven ounces of chloroform. (11) Four ounces of boric acid, powdered. 
(12) One tube of sterile white vaseline (for the baby). (13) Small and large 
safety-pins and bank-pins. 

If there is no nurse available before labor sets in, and it is necessary for the patient to- 
see to the cleansing of the above articles, she may be instructed to pin the douche pan, rub- 
ber sheeting, and hand-brushes separately in coarse kitchen towels and boil them for half 
an hour in an ordinary wash-boiler. The articles so boiled are then dried without removing 
the towels, put away, and not opened until the time of labor. The soft napkins, if these are 
to be used for vulval dressings, should, freshly laundered, be pinned, half a dozen in a 
package, in coarse kitchen towels, and put away until the onset of labor. The nurse is then 



THE MANAGEMENT OF LABOR. 517 

instructed to sterilize one package at a time by placing it in the oven until the outer covering 
is scorched. For sterilizing instruments and dressings in the oven of the kitchen range, one 
only requires a thermometer graduated to 200 C, so as to prevent the temperature rising 
too high, and to make sure that 140 C. is obtained. The absorbent cotton, the old linen 
for the baby's eyes, and the cheese-cloth are treated in the same way, the two latter being 
cut up into convenient pieces and sterilized as needed. It is sufficient that the abdominal 
binders be thoroughly laundered and pinned separately in freshly laundered towels until 
needed. It will be noted that the time-honored douche bag and tube have not been referred 
to, and this is because I do not employ douches except for positive indication; and, further, 
because I believe these articles should be part of the physician's outfit, sterilized and cared 
for under his direct supervision. 

Most or all of the articles contained in the above list of the "obstetric outfit " can to-day 
be obtained, sterilized in their final wrappers and ready for use, from many of the dealers 
in surgical dressings (notably, Van Horn & Co., New York; Kalish, New York; Johnson & 
Johnson, New York; Fraser & Co., New York), at prices for the outfit varying from four 
to thirty dollars. These obstetric outfits, cleansed and sterilized, are usually packed and 
sealed in a neat box, thus allowing the contents to be kept intact until needed. The con- 
tents of these outfits vary somewhat in detail, but the following list contains the essentials: 

(1) Agate-ware (square) douche pan. (2) Sterilized bed pads. (3) Sterilized vulval 
pads. (4) Sterilized absorbent cotton. (5) Sterilized absorbent gauze. (6) Two pieces 
of rubber sheeting or two ordinary rubber blankets, one for permanent labor bed and the 
second for the draw-sheet. (7) Abdominal binders. (8) Glass and rubber catheters. (9) 
Scrub- and hand-brushes. (10) Sterilized tape for cord, (n) Sublimate tablets; boric 
acid powdered; chloroform; ergot; borated talcum powder; soap; tube of sterile vase- 
line; safety-pins. 

2. Mother's Outfit. — (1) A number of merino or flannel undervests to be changed night 
and morning, to secure free skin action and prevent chilling. (2) Long night-dresses to be 
changed once a day. (3) Warm flannel wrap or dressing sacque. (4) Abdominal binders 
of soft muslin, half a yard wide and made to fit the figure at the sixth month of gestation. 
(5) Breast binders for large and pendulous breasts, plain muslin or ordinary corset-covers 
(see Part VI). An abundance of old linen sheets and a generous supply of towels. 

3. Baby's Outfit. — Should be plain, so as to withstand frequent washing; with long 
sleeves and high neck to secure warmth, since cold is so injurious to the newly born, and 
loose and light in weight, so as not to impede any organ in the body. (1) Soft flannel under- 
shirts with high neck and long sleeves, open in front so as to be easily removed or adjusted. 

(2) Four-inch, soft flannel binders to go round the abdomen and lap one-third, which should 
not be hemmed but overstitched, and should be secured to the child with tapes or sewed. 

(3) Cotton or linen diapers, which should not be of canton-flannel. When folded once, the 
diaper is half a yard square (to fasten with safety-pins). A second napkin is sometimes 
necessary. (4) Heavy or light, according to season, flannel slip to act as bath petticoat 
and dress, open and fastened in front. (5) Knit woolen socks reaching nearly to the knee. 
Cold feet are often an exciting cause of colic. White muslin slip may, if desired, be worn 
over flannel slip. When there is little hair on the head, a plain cambric or light flannel cap 
will prevent nasal catarrh. Baby basket: The ordinary contents are: (1) Bobbin. (2) 
Scissors. (3) Safety-pins. (4) Soft linen (4 by 4) in boracic acid solution for cleansing 
cord, eyes, and mouth. (5) Soft hair-brush. (6) Powder box of lycopodium or fine starch 
powder. (7) Tube of sterilized white vaseline. (8) Soft towels. (9) Complete change of 
clothing. (10) Woolen shawl, blanket, or wrap. 

4. The Physician's Obstetric Bag. — For several years I have experi- 
mented with different patterns of bags and cases in order to fulfil the 
requirements of private practice. I have always looked on leather obstetric 
bags with suspicion and fear, because of the difficulty of cleansing them, and 
because articles to be used in the lying-in room cannot be safely carried in 
them unless such articles and instruments are boiled immediately before use; 
further, I believe that the ordinary obstetric leather bag which has been from 
one case to another, in cabs and street-cars, which of necessity has had its 
interior soiled by bloody fingers and instruments, green soap, ergot, or othei 
drugs, has no place in the lying-in room in the present age of aseptic surgery. 
Leather obstetric bags can, therefore, not be recommended, because of the 
difficulty, if not impossibility, of cleansing them. Linen obstetric bags which 
can be boiled or sterilized by steam have been used in Germany. Duhrssen 
has an asbestos bag which can be sterilized by dry heat with the instruments 
in situ. Aluminium I have found unsuitable by reason of the uncertain com- 
position of the metal. The ideal obstetric case is one made entirely of metal 



518 PHYSIOLOGICAL LABOR. 

which will permit of cleansing by dry heat, steam, or boiling. Such a case 
may be contained for transportation in a suitable holder or bag. The bag- 
shaped cover is preferable because more convenient and conventional. The 
great disadvantage of a metal case, aside from its greater cost, is its additional 
weight. The aseptic metal obstetric case, which is here recommended, is the 
result of much experimenting, and weighs but six pounds more, including 
leather holder, than an ordinary leather obstetric bag. The weight of the 
case complete with glassware filled, and including a Tarnier forceps, is twenty- 
five pounds. This increased weight can be further reduced some two pounds 
by the use of lighter metal in the manufacture of the case. From actual expe- 
rience extending over a period of several years I believe that the inconvenience 
of the additional five or six pounds is more than overbalanced by the many 
advantages of such a case, not the least of which is cleanliness. 

The case practically consists of two trays, male and female, made of sheet-iron and 
enameled in white at a temperature of several hundred degrees (Fig. 616). The male or 
larger tray measures 17 X 8 X 6 inches, partially fits into a shallower female tray (17X8 
X 3% inches), leaving a space of two inches, in which space is contained a third tray made 
of canvas, with loops and compartments to contain the glassware of the case (Fig. 605). A 
leather holder or case covers both trays when fitted together, and strong straps hold all 
firmly together. My objects in having the case thus made of two trays, one large and the 
other small, and both enameled at a high temperature, with an inner canvas tray to contain 
the glassware, are as follows: 

1. The case is aseptic. The case proper can always be rendered sterile before being 
taken to a confinement by boiling, by baking in an ordinary kitchen oven, or by steam 
under pressure, as the size of the case permits its being sterilized in the medium-sized steam 
sterilizer of the market. No matter what the character of the complication attended, be it 
ever so septic, or instruments, douche bag, catheter, gown, etc., ever so soiled with pus or 
blood when thrown into the case to be carried away, the entire outfit can be placed in a 
wash-boiler and rendered sterile in a short period of time by boiling. 

2. Such a case furnishes us at the bedside, after the canvas tray is removed from the 
smaller tray and the contents from the larger, with two sterile receptacles which may be put 
to a number of uses and will often prove most valuable and convenient. For example: 
aside from a supply of hot water in an emergency, nothing more need be required to conduct 
a confinement than the case and its contents; as the larger tray, which holds, when half- 
full, six quarts, may be used to wash the hands and forearms in soap and water, and the 
smaller female tray, which holds, when half-full, three quarts, to disinfect the hand and 
forearm in sublimate solution. 

3. The length of this tray (seventeen inches) permits of the entire forearm being sub- 
merged in the sublimate solution, an advantage that will quickly be appreciated by the 
surgeon (Fig. 616). 

4. I am in the habit of using the smaller, female tray as a sterilizer. When in the 
course of labor indications point to the use of forceps, the instrument, still secured in its 
labeled canvas case, is placed in the smaller tray of the case and sent to the kitchen to be 
boiled for an hour. The boiling water is poured off in the kitchen, and, the forceps still in 
its case, is brought in the tray to the bedside, and the case is opened only after the patient 
and the operator's hands have been prepared for operation. 

5. The larger tray, again, by reason of its size, makes an excellent bath in which to 
plunge an asphyxiated child, and one has always at hand a convenient bath-tub in which a 
modified Byrd's method of artificial respiration can be carried on, the child being meanwhile 
submerged in very hot water (Fig. 616). 

6. The advantages of the inner canvas tray, which rests in the space between the 
two metal trays, will be readily appreciated. This tray is practically a canvas case 
measuring 17 X 8 X 2 inches, with a lid, and canvas handles at either end to lift it out of the 
smaller metal tray (Fig. 616). My object in using canvas here, with a separate loop or 
compartment for each piece of glassware or instrument, was to secure a noiseless tray for 
this part of the physician's obstetric outfit, one in which the articles are all in plain sight, 
so as to be selected at an instant's notice, and one, moreover, that can be repeatedly cleansed 
by boiling whenever soiled by bloody fingers, soap, vaseline, or ergot. 

7. The case as a whole is readily converted into an obstetric operating case by the 
addition of the desired instruments pinned in towels and placed in the larger of the two 
trays, for which purpose sufficient room has been provided. The length of the large tray 
permits of Tarnier's forceps, a cranioclast, and a cephalotribe being carried in it. 

Contents of the Case. — (a) In large male tray: (1) Clean apron. (2) Kelly pad. (3) 
Canvas lithotomy sling. (4) Four-quart sterile douche bag in canvas case. (5) Metal 
receptacle containing sterile vaginal and douche tubes and glass catheter. (6) Volsella, 




Fig. 6 i 6. — The Author's Obstetric Case. — (From a photograph.) 

519 



520 PHYSIOLOGICAL LABOR. 

dressing, needle and tongue forceps, and scissors in canvas case. (7) Obstetric forceps in 
canvas case. (8) Sterile cotton and plain gauze. (9) Five per cent, iodoform gauze. (10) 
Two sterile nail-brushes. (11) Rubber gloves. 

The two metfc.1 and the one canvas tray having been cleansed by boiling or by dry 
or moist heat, as already described, each of the various articles contained in the above 
list is cleansed in a different manner in order to secure surgical cleanliness. (1) The 
apron or canvas suit is simply freshly laundered. (2) The Kelly pad is cleansed with laun- 
dry soap, hot water and a brush, and finally with a 1 : 20 carbolic acid solution; should the 
pad be used about a case in which a suspicion of sepsis exists, it is boiled for half an hour. 
(3) The Kelly canvas lithotomy sling is made of canvas, galvanized iron rings, and brass 
buckles, and is boiled for half an hour after use. (4) The four-quart douche bag and tubing 
are, after use, scrubbed with hot water, soap, and a brush, rinsed in clean hot water, placed 
in its canvas case, and boiled for half an hour. The towel and bags are then allowed to dry 
in an enamel-ware vessel over the kitchen range, and when dry are placed in the case. (5) 
The metal receptacle containing the glass douche tubes and catheter is boiled together with 
the lithotomy sling and douche bag. Both metal receptacle and glass tubes are first, how- 
ever, scrubbed in a hot soda solution with soap and a brush. (6) The volsella, dressing, 
needle and tongue forceps, and scissors are, before being placed in the canvas case, simply 
scrubbed in hot soda solution with soap and a brush and then dried, as they are intended to 
be sterilized at the residence of the patient. (7) The obstetric forceps is treated in the same 
manner as the foregoing. (8) The sterile cotton, plain gauze, and iodoform gauze can be 
procured already sterilized from a dealer in surgical dressings. 

(b) In the canvas tray contained in the small female tray are: (1) Green soap (sterile). 
(2) Vaseline (sterile). (3) Gauze eye sponges (sterile). (4) Gauze cord dressing (sterile). 
(5) Chloroform. (6) Ergot. (7) Strong acetic acid (99.5 per cent.). (8) Sublimate 
tablets. (9) Fine boric acid (sterile). (10) Normal saline powders. (11) Silver nitrate 
solution (2 per cent.). (12) Tape for cord (sterile). (13) Silk and gut ligatures and 
needles (sterile). (14) Soft-rubber catheter (sterile). (15) Umbilical scissors. (16) 
Medicine-dropper. (17) Nail-cleaner. (18) Safety razor. (19) English catheter (No. 
16) with stylet. (20) Safety-pins. (21) Sterile gauze bandage for sling. (22) No. 8 
soft braided catheter opening at end. (23) Spring scales. 

Obstetric Operating Case. — For an operating set, add to the labor case the following: (1) 
Braun's cranioclast. (2) Dubois's scissors. (3) Smellie's perforator. (4) Three artery 
clamps. (5) Perineal retractor. (6) Tarnier forceps. The above six in canvas cases. (7) 
Scalpel and blunt bistoury. (8) Ether. (9) Rubber apron. (10) Sterile gauze bandages 
for slings. 

Use 0} the Case at the Bedside * — It is recommended in the use of this obstetric 
case at the bedside that the leather cover be removed in another room or the 
hall, and only the enamel- ware trays carried into the lying-in room. A small 
table is selected, placed at the head of the bed on" the side selected for vaginal 
examination and delivery. This table is covered with two or three freshly 
laundered towels. The large male case is lifted out of the smaller female 
tray and placed, with its contents undisturbed, at the distal end of the table 
(Fig. 617). The canvas tray is then lifted out of the small female tray and 
placed, with its lid thrown back, next to the large tray, and lastly and nearest 
the physician is placed the small female tray ready for the sublimate solution. 
If it is desirable to use the larger tray for hand washing, the articles contained 
in it may be arranged conveniently upon another portion of the table. Ordi- 
narily I do not disturb the contents of the larger tray until needed, and use 
running tap-water for hand cleansing with soap and water. 

The nail-cleaner, green soap, and one of the hand-brushes are now taken to 
the nearest tap of hot and cold water or to a basin of hot water, the coat is re- 
moved, the sleeves are rolled to the elbow, the nails are cleaned, and the hands 
and forearms are scrubbed and rinsed free of soap. Returning to the bedside, 
the clean gown is put on, the remaining hand-brush is dropped into a solution of 
1 : 2000 sublimate in the smaller tray, and the hands and forearms are scrubbed 
in this. Sterile rubber gloves are now drawn on. The patient having been pre- 
pared for vaginal examination and confinement, these are carried out forthwith. 
As labor goes on, the various articles are taken from the canvas and large tray as 

* My obstetric case is made for me by the Kny-Scheerer Co., 225 Fourth Avenue. New 
York. 



THE MANAGEMENT OF LABOR. 



521 



TOP OF 



N 

H 


> 

It! 

3) 

> 
-< 



STAND 



needed. Sterile cotton and plain gauze are at hand as needed for sponges in any 
of the three stages ; the Kelly pad for the rupture of the membranes or the second 
and third stages, or vaginal douches; the sterile douche bag and glass tubes for 
irrigation; the sterile vaseline for lubricating the fingers, if one desires to use it; 
chloroform for administration in the second stage ; sterile gauze sponges to wipe 
the baby's eyes and mouth on the expulsion of the head; sterile tape to tie the 
cord ; sterile dressing for the same ; clean scissors to cut the same ; nitrate of silver 
for the eyes; ergot for the end of the third stage or hemorrhage, as well as acetic 
acid for the latter, and a soft catheter to aspirate the baby's larynx. Should 
complications occur, we have the sterile lithotomy sling and the Kelly pad for 
drainage at the side of the 
bed; a safety razor to shave 
the vulva; a catheter to 
empty the bladder ; a volsella 
and dressing forceps and 
iodoform gauze to pack the 
uterus; needle forceps, nee- 
dles, scissors, silkworm-gut 
and catgut for lacerations of 
cervix or perineum; an En- 
glish catheter to replace a 
prolapsed cord; a tube to 
give intrauterine irrigations, 
and sterile bandages to use as 
slings for versions. 

If major obstetric opera- 
tions are demanded, we add 
to the above case the list of 
instruments already enumer- 
ated. If at any time in the 
course of labor the forceps, 
perineorrhaphy, or uterine 
packing set appears indi- 
cated, it is, in its original 
wrappings, placed in either 
the larger or smaller tray and 
sent to the kitchen to be 
baked or boiled. 

5. The Obstetric 
Nurse. — She should be free 
from cutaneous, suppurative 

disease or purulent coryza, nor should she recently have attended cases 
of infectious diseases, especially erysipelas, scarlatina, diphtheria, or typhoid. 
Oral sepsis on the part of the obstetric nurse has heretofore received no 
attention, and may possibly account for otherwise inexplicable cases of puer- 
peral infection. Two nurses, one for the mother and one for the infant, for 
at least the confinement and the first week of the puerperium, will generally 
secure a smoother and more rapid convalescence, and are strongly to be rec- 
ommended. The obstetric nurse should early in the case learn the attending 
obstetrician's routine management of mother and infant, and should not depart 
from it unless serious emergency demand it. An excellent plan is for the 
physician to provide a printed resume of his general treatment of the pregnant, 





Fig. 



617. — Plan showing Arrangement of Lying-in 
Room. 



522 



PHYSIOLOGICAL LABOR. 



parturient, and puerperal woman, and have the nurse familiarize herself with 
the same. 

6. The Lying-in Room. — The lying-in room should not have been used 
by any one suffering from infectious disease, and it should be of good 
size, well ventilated, and with as much sunlight as possible. Care should be 
taken as to the plumbing of the house, and the room should be as far removed 
from drains and water-closets as possible. It should be thoroughly cleaned and 
all unnecessary draperies and upholstered furniture removed. The tempera- 
ture should range from 66° to 72 F. A bare floor is preferred to a carpeted one, 
but in case of the latter, the carpet may be protected by an oil-cloth or a rug 
at the side of the bed. 

7. The Labor Bed. — The bed and bedding should be perfectly clean. 
The bed should be accessible from both sides and out of all draughts. It should 
not be too low. Soft beds should be avoided, a hair mattress being preferable. 
In all cases requiring operative interference it is much better to deliver the 
patient upon a table. Over the middle third of the mattress a piece of rubber 
sheeting, oil-cloth, or tarred paper, a yard or more in breadth, is placed and 
pinned firmly with safety-pins. A clean bed-sheet is then placed over the 
entire mattress and pinned down. This is the permanent bed (Fig. 618). Over 




J PERMANENT LABOR BED{™r E 



SHEETING' 



Fig. 618. — Plan of Arrangement of the Permanent and the Temporary Labor 

Beds. 



the site of the permanent rubber sheeting, a second rubber sheet of the same 
size is placed. This is the foundation of the temporary bed, and is of the nature 
of a draw-sheet (Fig. 618). Upon this second rubber sheet may be placed one of 
the absorbent obstetric pads now commonly sold, or several sheets folded to retain 
the discharges from the vagina. During labor the absorbent pad may be renewed 
as necessary, and the last one, together with the upper rubber sheet, may be re- 
moved at the completion of labor. The permanent rubber sheeting remains for 
several days of the puerperium, to protect the mattress. A piece of oil-cloth or 
waxed cloth or a freshly laundered bath blanket should be placed at the bedside 
to protect the floor. 

8. Articles to be in Readiness at Time of Labor. — (Obtainable in every 
household. ) ( 1 ) Arrangement for an abundant supply of hot water. (2 ) A bowl 
for vomited matter. (3) Two clean earthen-, agate-, enamel,- or paper- ware 
bowls for hand cleansing. (4) A clean bowl for the placenta. (5) Three 
pitchers : one for boiling water, one for cold boiled water, and one for mixing 
antiseptic solutions. (6) A clean cup or tumbler with boric acid solution and 
gauze or old linen wipes for the baby's eyes. (7) A half-dozen freshly laundered 
old linen sheets to serve as bed pads or pilches. (8) An abundant supply of freshly 
laundered sheets and towels. (9) A change of night-clothing, warmed, for the 



THE MANAGEMENT OF LABOR. 



523 




mother. (10) A warm blanket to receive the baby. Of these articles, the four 
bowls, the cup, and the three pitchers should be scrubbed with soap and water 
and boiled in a wash-boiler or at least scalded out. It is 
sufficient that the old sheets to be used as bed pads and the 
usual bed-sheets and towels be freshly laundered. For special 
cases, however, — for example, breech presentations, — it is de- 
sirable that half a dozen towels are sterilized by boiling or by 
dry heat in an oven, as described above. 

Response to Summons. — A physician engaged to attend a 
case of confinement should, when summoned, respond as 
promptly as possible, since by the rigid observation of this 
rule it is frequently the case that complications which may 
easily be remedied at an early stage may present the gravest 
difficulties if not treated till a later period. Examples are 
malpresentation, malposition, faulty attitude, prolapse of the 
small parts, severe perineal laceration, postpartum hemor- 
rhage, and fetal asphyxia. 

Preparation of the Physician. — (See Asepsis in Obstetrics, 
page 152.) 

Preparation of the Patient. — The pubic hair, especially 
when long or thick, should be clipped moderately short ; then, 
whether the bowels have recently moved spontaneously or not , 
a full enema of soapsuds (Oij) and glycerin (one ounce) should 
be administered. After the onset of labor the use of the toilet 
by the patient should be forbidden in order to lessen the dan- 
gers of infection, and the commode or vessel must then be sub- 
stituted. At this time and subsequently the patient should 
be encouraged to empty the bladder frequently and com- 
pletely. 

The Ante-partum Bath. — The traditional ante-partum 
tub bath has recently * been the subject of severe criticism 
from the standpoint of asepsis. Not only is the parturient 
woman at the end of such a bath immersed in a dilution of 
her own dirt, but, as has been shown experimentally, the in- 
fected water often enters the 
vagina of both primiparae and 
multiparas. Moreover, under 
such conditions the danger of 
nipple infection is always pre- 
sent. The ideal ante-partum 
bath, then, would be for the patient to stand or sit 
under a running stream of boiled water, thus elimin- 
ating another possible source of septic infection of 
the parturient woman. This can, in maternity 
hospitals, readily be accomplished under a warm 
shower-bath and in some dwellings in private prac- 
tice. When a shower of boiled water is not available, 
the author instructs the nurse to place, the patient in a bath-tub (Fig. 621) and to 
pour several gallons of boiled water, allowed to cool to the proper temperature, 
over the shoulders of the patient, the patient at the same time being instructed 

Gynakologie," Mar. 2, 1901; and Strogan: " Centralblatt f. 





Fig. 619. — White 
Linen Suit 
for Obstetric 
Work. 



Fig. 620. — Case Containing 
Linen Suit for Obstetric 
Work. 



* Sticher 
Gynakologie, 



"Centralblatt f. 
Feb. 9, 1901. 



524 PHYSIOLOGICAL LABOR. 

thoroughly to scrub the external genitals and body generally with a coarse, clean 
wash-cloth and green soap, the nurse using the soap on the back and shoulders. 
All soap is finally washed off and the bath completed with several quarts of 
sublimate solution (i : 5000 f). The patient's external genitals are finally 
thoroughly cleansed by the nurse with absorbent cotton and a 1 : 2000 solution 
of sublimate. The surface of the body is now dried with brisk friction. A 
sterile vulval pad as a temporary occlusion dressing is then applied and pinned 
to a waist-band made from a clean gauze bandage (Fig. 641). If a bath-tub 
is not available, the following procedure is recommended : (1) Have the patient 
take a sponge-bath of hot water and soap, using not a sponge but a clean wash- 
cloth. (2) The nurse is instructed to cut the pubic hair short, if it is long or 
thick, with scissors. (3) The nurse now with a soft hand-brush or absorbent 
cotton scrubs with soap and hot water the external genitals, pubes, and inner 
sides of the thighs, and cleanses the vulval canal from above downward with 
absorbent cotton and soap and water. (4) The parts are now rinsed off with 
clean water. (5) The same parts are then with absorbent cotton and 1 : 2000 
sublimate solution given a final cleansing, always toward the anus, care being 
taken to include the vulval canal with the sublimate solution. A sterile vulval 
pad or gauze is now applied to the external genitals as a temporary occlusion 
dressing, and fastened by a T-bandage. In every method of cleansing the 
vulval canal and external genitals the greatest care must be used to avoid 
the production of erosions by stiff brushes or rough handling, as these lesions 
may subsequently become infected. 

Ante-partum Vaginal Irrigation. — It now appears that the consensus 
of opinion of a few years ago as to the sterility and germicidal qualities of the 
vaginal mucus was somewhat premature. It is certain that the vagina in the 
healthy pregnant woman very often contains bacteria, often streptococci, and 
that in a majority of cases the germs enter the uterus immediately after de- 
livery. 

It is nowhere maintained that this phenomenon is inherently pathological; 
but it cannot be doubted that sometimes this is the case, and it is more than 
likely that these bacteria are responsible for the residual morbidity with oc- 
casional death which cannot be made to vanish with the strictest asepsis. This 
source of morbidity, if reached at all, may be reached only with ante-partum 
antisepsis. 

The Examination of Labor. — The Obstetric Examination. — On enter- 
ing the lying-in chamber the physician should note in a general way the physical 
and mental condition of the patient, and should she be, as is naturally in most 
instances the case, the victim of anxiety and nervousness, he should endeavor 
by his words and demeanor to reassure her and to quiet her apprehension. He 
should then take the pulse and temperature, not forgetting that the former 
is often increased by nervous influences, and, if time permits, a brief but careful 
examination of the heart and lungs is advisable, if this has not already been 
attended to (see page 152). In the obstetric examination it is advisable for 
the physician to follow some routine in order to avoid needless repetition and 
to secure thoroughness. (1) The patient has been prepared for labor as de- 
scribed on page 523. She is placed on a couch or bed in the dorsal posture, 
with the head but slightly raised, clothed only in her night-dress and covered by a 
sheet. (2) Unless such information has already been obtained at the exami- 

t Statistical proof from the Imperial Maternity Asylum of St. Petersburg shows a fall 
of 7.4 per cent, in fever in the puerperal woman by the substitution of the shower for the 
old-fashioned tub bath. 



THE MANAGEMENT OF LABOR. 525 

nation during pregnancy, it is well at this point to record the age, parity, 




Fig. 621. — The Ante-partum Bath. 
former health, especially children's diseases of the individual and at "what 



528 PHYSIOLOGICAL LABOR. 

age she first walked; the type and date of her last menstruation; the history 
of her present pregnancy, and the character of her former pregnancies, labors, 
and puerperiums. The patient should be exposed as little as possible, hence 
for the external examination two sheets may be used, one to cover the body 
and one the lower extremities from the pubes down, the upper sheet being 
raised to expose the abdomen (Fig. 199). For the external examination in the 
dorsal posture, the patient may be covered with a sheet, as shown in Fig. 199. 
(4) The physician renders aseptic his hands and forearms as described on page 
154, not forgetting that his coat should be removed and his forearm bared 
to the elbow. The woman physician should see to it that her sleeves are made 
so as to allow of their being rolled up. The use of sterile rubber gloves is to- 
day the best means for the prevention of infection. 

External Examination. — Having attended to the foregoing prelimin- 
aries, it is now in order to make the external examination, and this should 
always, except in case of emergency, precede the internal, because: (1) It 
enables one to make the latter more intelligently; and (2) it helps one to gain 
the confidence of the patient and prepare her for the internal examination. 
This part of the examination, often neglected and usually undervalued, is 
of the highest importance. By many authorities it is considered almost equal 
in value to vaginal examination, while others who have made a careful study 
of this method claim that by its frequent use they can dispense altogether 
with the internal examination in a large proportion of cases. In the first stage 
of labor this r examination will not differ greatly from the external examination 
already described under the " Examination of Pregnancy," page 152. Exami- 
nations should be made between the pains, since the action of the fetal heart 
is more rapid during a pain, and the uterine contractions render satisfactory 
palpation difficult. Although the diagnosis by external manipulation is some- 
what more difficult at this time than before labor, it is usually possible to obtain 
a satisfactory idea of the position and presentation. Important facts to be 
noted are: (1) The position and presentation (see page 160); (2) the rate 
and character of the fetal heart-sounds (see page 132); (3) the condition of 
the bladder as to distention; (4) the size of the fetal head and whether or not 
it has entered or can be made to enter the pelvic cavity; (5) and the strength, 
duration, and frequency of the uterine contractions. The occurrence of the 
pains at regular intervals and the contraction of the uterus during a pain, 
which may be appreciated by a hand placed on the abdomen, are of importance 
in distinguishing the onset of true labor. The sinking of the uterus, referred 
to in the section on the symptoms and signs of pregnancy, which occurs during 
the last two weeks of pregnancy, is also of some significance. The characteristic 
shape of the abdomen when the membranes have ruptured and the head is 
low in the vagina soon becomes familiar to the observer and denotes that the 
patient is far advanced in labor. 

Pelvimetry. — Should the patient be a primipara who has not been sub- 
jected to the examination of pregnancy (see page 152), the routine external 
pelvic measurements — namely, the crests, spines, trochanters, obliques, and 
external conjugate — should be taken, and if pelvic deformity exist, as further 
indicated by the internal examination, we should not hesitate to make a thor- 
ough internal examination under nitrous oxid or ether, passing the whole hand, 
if necessary, into the pelvis to secure accurate data of the available space at 
the pelvic inlet (see page 180). If the patient be a multipara, all these careful 
measurements in private practice are not necessary if the previous children 
have been of ustial size arid the labors uneventful. 



THE MANAGEMENT OF LABOR. 



527 



Internal Examination. — After the external examination, the patient 
having already been prepared as described on page 523, the nurse should place 




Fig. 622. — Vaginal Examinations during Labor. Position of the Patient and 
Separation of the Vulva; Introduction of the Fingers with the External 
Genitals Exposed to View. (Method recommended.) 

her in the dorsal posture, with thighs flexed, parallel with the edge of the bed 
(Fig. 622). The external genitals and vulval canal are again cleansed from 
before backward by the nurse with 1 : 2000 sublimate solution by means of 



528 



PHYSIOLOGICAL LABOR. 



'*§* 










absorbent cotton. No unsterilized object, hand, instrument, dressing, or cloth- 
ing, should touch the genitals, which during the course of labor are covered 
with a sterile vulval pad. The physicians's hands and forearms are re-sterilized 
(see page 154) and the ostium vaginae is exposed by separating the labia with 
the sterile thumb and finger of the left hand (Fig. 622). The sterile first and 
second fingers of the right hand are now passed directly into the vagina, having 

come in contact with nothing from 
r— > the sublimate solution to the va- 

ginal entrance (Fig. 622). No towel 
or vaseline should be used, the ex- 
amination being made while the 
hand is still moist with the bichlo- 
ride solution. 

The First Vaginal Examina- 
tion. — It is desirable to make a 
careful vaginal examintion as early 
as possible in the first stage in ore 
to verify the information, as to 
fetal position and presentat 
which may have been obtainec 
external palpation, and to det^ 
mine the existence or nonexistence 
of conditions in the pelvis or soft 
parts which would prove obstacle.': 
to delivery, unless the information 
has already been obtained at the 
examination during pregnancy 
(page 152). In the first vaginal 
examination during labor we 
should strive to determine: (1) The 
condition of the vulva and vagina 
as to dilatability and the presence 
of lubricating mucus; (2) the con- 
dition of the bladder and rectum ; 
(3) the condition of the cervix as 
to dilatability and degree of dilata- 
tion; (4) is pregnancy present ? (5) 
is the woman in labor? (6) what is 
the stage of labor? (7) the presence 
of the ' ' bag of waters ! ' and whether 
it becomes tense during a pain, an 
important point in distinguishing 
true from false labor pains ; (8) the 
presentation and position; (9) the 
internal conjugate diameter; (10) 
any apparent disproportion be- 
tween the presenting part and the capacity of the pelvis; (11) the effectiveness 
of the pains on the os, membranes, and presenting part. (12) This examination 
should also carefully confirm the results of the examination during pregnancy as 
to the presence of pelvic deformity or obstruction in the soft parts and as to the 
fetal position and presentation. If any suspicion of pelvic deformity exist, the 
true conjugate should be estimated, the height of the symphysis noted, the lateral 




DURING 



Fig. 623. — Vaginal Examinations 

Labor. The External Genitals are not 
Exposed to View. (This method is not re- 
commended.) 



THE MANAGEMENT OF LABOR. 529 

surfaces of the pelvis palpated, and the methods of determining the actual degree 
of pelvic deformity applied ; these have already been described under the " Exam- 
ination of Pregnancy," page 152. If the vertex presents and descends regularly 
with the pains, and if the patient's general and local condition is satisfactory, in- 
terference, and especially the passing of the finger through the os uteri, owing 
to increased danger of sepsis, is to be scrupulously avoided. Noticeable delay, 
however, in the progress of labor should be carefully investigated, and, if 
necessary, under anesthesia, as will be described in the section on delayed 
labor. 

Repetition of Vaginal Examinations. — It was formerly the custom to 
make frequent examinations during the whole course of normal labor, and this 
is still taught in some text -books, but the consensus of modern teaching is to the 
effect that such a course is unnecessary and dangerous (see page 153). It is true 
that, with proper care as to asepsis, the danger of infection is limited, but it never- 
theless exists, since even with the greatest care it is impossible to exclude all 
sources of contamination. Examinations are also annoying to the sensibilities of 
•3 patient , and when frequently repeated they sometimes become extremely pain- 
They tend to remove the vaginal mucus which nature has provided for lubri- 

ing the parts and to cause erosions of the mucous membranes which may serve 
starting-points for septic infection. Their frequent repetition has in many 
jases a bad effect on the nervous system, and undoubtedly contributes at times 
reflexly to delay the progress of labor. It is nevertheless true that it is the 
duty of the attendant to keep himself informed of the progress of his patient, 
and that this may, at least in the case of beginners, require two or three 
vaginal examinations. Increasing experience diminishes .the necessity for 
vaginal examinations, and it should be the effort of the physician to acquire 
such familiarity with abdominal palpation and the clinical history of labor that 
the necessity for frequent examinations ma}- not exist. 

Having made the first examination, the attendant should endeavor as far as 
possible to determine the further progress of labor by external palpation and by 
observation of the patient, but if in doubt, he should repeat the examination often 
enough to satisfy himself as to the non-existence of a delayed first stage. Exact 
rules as to the frequency of examination cannot be given, but modern investi- 
gation tends to the conclusion that in normal cases one careful examination early 
in the first stage and another after the rupture of the membranes should be 
sufficient for the experienced accoucheur. Examination after rupture of the 
membranes may guard one against the neglect of face presentation, which some- 
times occurs at this time, and of prolapse of small parts of the fetus or of the 
cord; it determines also the exact position of the head. It cannot be too em- 
phatically stated that pregnant, parturient, and puerperal women can be fatally 
infected by a single careless internal examination; that infection is almost 
invariably transmitted by the examining finger, and occasionally by instruments, 
clothing, dressings, bathing, and the patient's hand; the infectious material 
is found everywhere, and no matter what the environment, the danger of infec- 
tion is always present, therefore one should always adhere to a strict routine 
of cleanliness. Some danger of infection is always present, therefore internal 
examinations should be as infrequent as possible. With proper precautions 
of vulval and hand cleansing, vaginal examinations may be said to be relatively 
harmless. The same statement under the same conditions may be made re- 
garding intrauterine manipulations. Yet we do not lightly undertake intra- 
uterine manipulations in the absence of a positive indication. Clinical expe- 
rience as well as bacteriology has taught us in the past semidecade to look upon 
34 



530 PHYSIOLOGICAL LABOR. 

ante-partum, intra-partum, and post-partum vaginal manipulations in the same 
light as that of intrauterine manipulations of a decade back. 

In many instances it is possible to conduct a labor without any internal 
examination, since the chief information gained through the vagina is the stage 
of dilatation of the cervix, and this is often not specially important to know. 
Leopold and Sporling * and Leopold and Orb f believe that it is possible to 
conduct safely 90 per cent, of all labors without any other than external methods 
of examination. Among the first 1000 cases of these observers there were only 
6.5 per cent, of errors of diagnosis, while in the second thousand the percentage 
was only 1.77 per cent. 

MANAGEMENT OF THE FIRST STAGE. 

This stage commences with the onset of true labor pains and ends with the 
full dilatation or dilatability of the os uteri. The conduct of the obstetrician 
during this stage is usually passive, provided no evidences of maternal or fetal 
dystocia have been discovered at the examination either during pregnancy or 
during labor. 

Posture of the Patient. — In the absence of any abnormal conditions, such as 
hemorrhage, placenta praevia, or prolapse of the funis, the patient may follow 
pretty much her own inclinations as regards sitting up, walking about, or lying 
down. In prolonged labor, especially in primiparas, sitting erect or walking 
about the room is of advantage in assisting dilatation of the os and fixation of 
the head. As soon, however, as the os is nearly dilated or dilatable, and the 
membranes are about to rupture, the patient must be placed in the dorsal or 
lateral recumbent position, until the membranes rupture or are ruptured arti- 
ficially. Should rupture occur when the patient is in the erect posture, there is 
danger of prolapse of the cord or of one of the fetal extremities. 

Presence of the Physician. — His presence in the lying-in room is not usually 
advisable at this time, but in multiparae and in rapidly progressing labors in 
primiparas it is best that he be within call. 

Vaginal Examination. — Repetition of the examination during labor (page 
153) is usually not necessary, although many advise an immediate examination 
when the membranes rupture so as to exclude prolapse of the funis. Frequent 
abdominal palpation will generally suffice for following the progress of labor (see 
page 162). 

Food, Drink, Sleep, Attention to Bladder and Rectum. — In prolonged labors 
the patient should be encouraged to take at intervals during the first stage small 
quantities of liquid nourishment, such as plain milk or milk and carbonic water, 
or simple broths or soups, such as chicken, clam, or beef. I am accus- 
tomed to proscribe the use of solid food, in view of the fact that ether or 
chloroform narcosis may subsequently be demanded. No restriction should be 
placed on the amount of water desired by the patient. When there is nausea 
or vomiting, very hot clear tea or black coffee can advantageously replace the 
water. In the absence of a positive indication alcohol should be avoided. The 
patient should be induced and aided to sleep, if possible, between the pains, 
especially if lafbor commences at night, since a sleepless night is a bad prepara- 
tion for labor. The patient should empty the bladder at frequent intervals, 
since its distention is a common cause of delay at this time. The catheter 
should be avoided. If the rectum has not already been emptied, or if it refills 
again, a copious enema should be given. 

* " Arch, fur Gyn.," xlv, 339-371. t " Arch, fur Gyn.," xlviii, 304-323. 



THE MANAGEMENT OF LABOR. 531 

Use of the Voluntary Forces. — In any but exceptional cases voluntary 
bearing-down efforts on the part of the patient, either with or without the aid of 
bandages of bed-sheets used as traction straps for the hands, should be dis- 
couraged. Such proceedings only fatigue the patient and usually do not aid 
the progress of labor. 

Care of Membranes. — Every precaution should be taken against the acci- 
dental rupture of the membranes, either by vaginal examination or by sudden 
movements of the patient, in order to avoid a dry labor and its consequences 
(see page 616). * 

Anesthesia. — (See Operations, Part X.) 



MANAGEMENT OF THE SECOND STAGE. 

This stage commences with full dilatation or full dilatability of the os, and 
ends with the complete expulsion of the fetus or fetuses. 

Posture of the Patient. — At or near the end of the first stage the patient 
should be placed in bed, and, as a rule, must remain there until the completion 
of the second stage, the bed-pan being used for evacuations of the bladder and 
bowels. As the period of fetal expulsion approaches, the patient is placed in 
the position, dorsal or lateral, preferred by the physician, and the nurse is 
instructed to draw up and pin at the shoulders the night-clothing to pro- 
tect it from soiling. An ordinary bed-sheet may be pinned about the waist 
like a skirt to cover the lower part of the body and as a further protection 
against soiling. 

Presence of the Physician. — Usually he should not absent himself during 
this time. 

Vaginal Examination. — In the absence of dystocia, abdominal palpation 
may be relied upon for determining the course of labor (page 160). 

Food, Drink, Sleep, Attention to Bladder and Rectum. — The same principles 
apply here as in the first stage, with the exception of sleep (page 530). The 
second stage is usually so short that it is rarely necessary to feed the patient. 
Care should be taken, however, that both bladder and rectum are empty at this 
time. The presence of a distended bladder can be determined by external 
examination. 

Use of Voluntary Forces. — In the second stage, and especially when it is 
protracted, the patient should be encouraged to bear down during the pains. 
Much can be accomplished by instructing the woman to hold her breath and bear 
down as a contraction reaches its height. If the contractions are severe and 
painful and the patient does not bear them well, she may be induced to bear 
down by being allowed to inhale a few drops of ether or chloroform at the begin- 
ning of each pain. Other legitimate and simple measures to overcome inefficient 
contractions at this time are having the patient repeatedly assume a sitting 
posture on the edge of the bed, or even on a chair; pulling upon the hands of the 
nurse ; bracing the feet against the foot of the bed ; pulling with both hands upon 
slings made of stout roller bandages fastened to the bed below the feet. (See 
Prolonged Labor.) For a too rapid expulsion anesthesia is our sheet-anchor; 
instructing the patient not to bear down is also useful. 

Artificial Rupture of the Membranes. — The membranes usually rupture 
spontaneously at or near the completion of the second stage after their purpose 
has been accomplished. Earlier rupture is not uncommon. A common and 
pernicious practice is the early artificial rupture of the membranes to accelerate 
labor. As a rule, they should not be interfered with, even though they distend 



532 PHYSIOLOGICAL LABOR. 

the vulva. Indications may arise which demand their artificial rupture. (See 
Operations, Part X.) 

Anesthesia. — (See Operations, Part X.) 

Perineal Protection.* — When the presenting part approaches the pelvic 
floor and vulva, preparations are to be made to protect the perineum from 
rupture. The most important part of the management of the second stage is 
the prevention of perineal tears. Lacerations of the fourchette in primiparae 
and superficial tears about the vulval orifice often occur, but these readily heal 
with simple asepsis. Deep tears, however, are avoidable in normal cases. The 
great importance of avoiding rupture of the perineum cannot be overestimated. 
It is scarcely an exaggeration to state that one-half of the gynecological cases 
owe their condition directly or indirectly to rupture of the muscles of the pelvic 
floor during labor. The causes of perineal laceration are three in number, 
namely: (i) Relative disproportion in size between the presenting part and the 
pelvic outlet; (2) too rapid expulsion, so that tearing instead of stretching re- 
sults; (3) and faulty mechanism of labor whereby a larger circumference of the 
presenting part than necessary passes through the outlet. 

Prophylaxis depends upon the cause.! If there is great disproportion in 
size or abnormal rigidity of the outlet, abundance of time must be given to the 
muscles of the pelvic floor to stretch sufficiently without tearing to permit of 
the passage of the fetus. Preliminary digital stretching as well as the use of 
chloroform will assist in the relaxation of these muscles, and if all attempts fail 
and conditions do not permit of further delay, episiotomy, properly performed 
and repaired, is preferable to deep perineal rupture (see Obstetric Operations, 
Part X). The chief ends in view are (1) to prevent too rapid expulsion; (2) to 
preserve the normal mechanism of delivery, and, if possible, (3) to effect delivery 
of the head between the pains. 

t. The too rapid advance of the head can be prevented by inducing the patient 
to refrain from bearing-down efforts, to breathe rapidly during the pains, and to 
cry out during the emergence of the head ; by the manual retardation of the pre- 
senting part and by the administration of chloroform or ether. Partial anesthesia 
is an invaluable resource, aiding relaxation of the tissues, preventing too rapid 
expulsion, and allowing of complete control of the case. The advance of the 
head should be retarded by pressure applied not to the perineum but to the 
presenting part. No attempt should ever be made to support the perineum 
directly, and all methods of perineal protection which depend upon intrarectal 
manipulations of any character should be carefullv a\-oided, as liable to injure 
the rectum, produce spasm of the pelvic floor muscles, and favor subsequent 
infection of the genital tract or the eyes or umbilicus of the child. 

2. The normal mechanism of delivery should be aimed at so as to secure the 
smallest possible diameters of the presenting part to pass through the parturient 
outlet. A valuable point in vertex anterior positions is so to retard extension 
of the head, until the external occipital protuberance has passed the subpubic 
ligament, that the smallest or suboccipito-bregmatic circumference (Fig. 581) 
may be the one to engage and pass through the outlet. 

3. Delivery of the head between the uterine contractions has a distinct advantage 
in that we have a relaxed instead of a rigidly contracted pelvic floor to deal with. 
Method second or third will accomplish this end. 

* For the varieties, frequency, etiology, mechanism, symptoms, diagnosis, prognosis, 
and prophylaxis of perineal injuries, see Pathological Labor, Part V. For the treatment of 
the same, consult the section on Obstetric Surgery, Part X. 

t Compare Pathological Labor, Part V. 



THE MANAGEMENT OF LABOR. 



533 



Methods of Perineal Protection. — Any of the various postures of the patient 
may be selected, but I advise the left lateral prone posture for left positions of 



FIRST. 




SECOND. THIRD. 

Fig. 624. — Perineal Protection, showing Three Methods. 



the presenting part, and the right lateral prone posture for right positions. It 
is generally admitted that the lateral position is most favorable to perineal 
preservation. In this position the force of violent pains is diminished, since 




534 PHYSIOLOGICAL LABOR. 

the expulsive power here is actually a resultant of two divergent forces. In the 
lateral and latero-prone positions the intra-abdominal pressure is also weakened, 
and the perineum is always under ocular control. Further, disinfection may be 
carried out more completely in the lateral decubitus. In the dorsal posture the 
weight of the head carries the latter away from the pubic arch and against the 
perineum; this condition is not favorable to the latter. While this disadvantage 
may be offset by the upward pressure of the anterior segment of the peri- 

■«* neum toward the symphysis, 
the former thereby becomes 
((B^^^^b*- ischemic, thin, and more prone 

to rupture. The thighs, how- 
ever, should not be too ener- 
getically flexed, otherwise the 
perineum will be put upon a 
dangerous stretch. After de- 
livery the lateral posture must 
/be quickly changed to the dorsal, 
lest air embolus result. Among 
primitive people a squatting or 
kneeling position is often in- 
stinctively adopted during de- 
Fig. 625. — Cleansing the Eyelids Immediately livery, but it cannot be claimed 
after the Birth of the Head. that ' suc h postures favor the 

perineum, as labor under these 
circumstances has a precipitate character. While labor may be shortened and 
facilitated by these attitudes, the safet}^ of the perineum would seem to demand 
that the lateral position should be assumed during the moment of expulsion. 
Any of the following methods may be utilized, as all are subservient to the prin- 
ciples already laid down. The principle in all methods of direct manual protec- 
tion of the perineum is to delay expulsion of the presenting part in such manner 
as to realize all the advantages of the elasticity of the perineum. The degree of 
latent elasticity of this structure may be determined by inspection. The fetal 
head, or other presenting part, should 
be supported rather than the perineum. 
In fact, the attempt to support the latter ^^*>- 
is attended by danger. 

Method one: The patient is placed in ^BB 

the lateral prone posture. In the left 
lateral prone posture the physician, 
seated at the bedside behind the patient, 

passes the left hand and forearm over 

i.-u • -L4. j.i»* -l r x-l. 4.- ± j Fig. 626. — Little Finger Wrapped with 

the right thigh of the patient and uses Gauze for Removing Mucus from the 

the fingers of this hand to retard the exit Child's Mouth. 
of the presenting part, and also to assist, 

to a small extent, the normal mechanism of labor until the pelvic floor is suffi- 
ciently stretched to allow the passage of the fetus without laceration (Fig. 624). At 
the same time, with two or three fingers of the right hand placed upon the protrud- 
ing head, and without touching any part of the maternal tissues, control of the 
expulsion and regulation of the head movements can readily be carried out (Fig. 
624). In this method both hands are used to control a too rapid advance and con- 
jointly to regulate the head movements, so as to secure the most favorable mech- 
anism of head delivery. Chloroform or ether will greatly assist our endeavors. 



THE MANAGEMENT OF LABOR. 



535 



Method two: The posture of the patient and the position of the physician are 
the same as in Method One. Chloro- 
form or ether is invaluable. The posi- 
tion and functions of the left hand are 
the same as above. At the same time, 
with the fingers of the right hand (Fig. 
624) placed on each side of the coccyx, 
over the extremities of the bitemporal 
diameter of the fetal head, the pre- 
senting part is pushed up as close to 
the subpubic ligament as possible, 
thus making use of all the available 
space of the pubic arch. The use of 
chloroform or ether to the obstetric 
degree, and the delivery of the pre- 
senting part during perineal relaxa- 
tion between the pains, by pressure 
with the fingers on either side of the 
coccyx, or by expressio foetus- (Part X), 
will greatly lessen the chances of rupture 




Fig. 627. — Method of Loosening and Car- 
rying the Cord over the Head when 
the Former is Tightly Coiled about the 
Child's Neck. 



Extension and delivery of the head 




Fig. 628. — Method of Shoulder Delivery. The Head is Raised to Bring the 
Neck Close to the Pubes, and the Anterior Shoulder well behind the 
Symphysis, thus Encouraging Delivery of the Posterior Shoulder First, 
with the Cervico-acromial Diameter Engaging. 



536 



PHYSIOLOGICAL LABOR. 



should never be permitted until the external occipital protuberance has been 
born beyond the arch of the pubes. 




Fig. 629. — Method of Shoulder Delivery. The Anterior Shoulder is here Born 
First, and the Head is Raised to Encourage Expulsion of the Posterior 
Shoulder. 




\ 

Fig. 630. — -Supporting the Child during the Expulsion of the Trunk and Legs. 
Note that the trunk is grasped at the pelvis, leaving the chest and abdomen free from 
pressure. 



THE MANAGEMENT OF LABOR. 537 

Method three: Lateral posture and chloroform or ether, as above. In the left 




liTTSCES 5ti!SE§ 



Fig. 631. — Proper Position of the Child Immediately after Delivery. It lies on 
its right side and the buttocks are raised to favor the flow of mucus and foreign sub- 
stances from the mouth. — {From a photograph taken at the Emergency Hospital.) 



lateral posture the right, and in the right posture the left, hand is used for perineal 
protection. In the dorsal posture of 
the patient either hand is available. 
By the natural forces or by pres- 
sure upon the fundus the head is 
made to distend the vulva suffi- 
ciently to enable the middle finger 
of the perineal hand to obtain a 
point of pressure upon the fore- 
head of the fetus by reaching be- 
hind the anus but without entering 
the rectum (Fig. 624). The thumb 
of the hand is then placed upon 
one labium majus and the index- 
finger upon the other over the 
parietal protuberances of the ad- 
vancing head (Fig. 624), and serve 

4. j .L-L 1 -u- j j -u 1 Fig. 6^2. — Method of "Stripping" the Um- 

to draw the labia inward and back- MLI ^ L CoRD TO Remove the Excess of 

ward and prevent undue strain Wharton's Jelly. 




538 



PHYSIOLOGICAL LABOR. 




\ 



Fig. 633. — Method of Tightening the Liga- 
ture about the Umbilical Cord. Note the 
position of the thumbs to prevent injury to 
the ring from cutting or breaking of the liga- 
ture. 



upon the posterior commissure, which lies in plain sight above the web between 
the thumb and forefinger. Pressure of the fingers upon the parietal eminences 
prevents the too sudden advance of the head, while the middle finger reaching 
behind the anus and protected by a sterile towel exerts pressure upon the fore- 
head, and at the proper moment during the relaxation between the pains increases 

head extension and slowly shells it 
out through the vulval opening. 
Moderate fundal pressure with the 
free hand may assist in the manceu- 
ver. 

Cleansing of Eyes and Mouth.^ 
After the delivery of the head, the 
eyelids should be carefully cleaned 
by means of a soft jinen cloth and 
sterile water, or boric acid solution ; 
a separate wipe being used for each 
eye and the lids washed, from the 
nose outward, free from all mucus, 
blood, or meconium. At this time 
also the lips and nose are in like 
manner wiped free of mucus, and 
the little finger, wrapped with a 
piece of moist linen, is passed 
into the child's mouth and any 
accumulated mucus removed by an outward sweep of the finger (Fig. 626). 

Care of the Cord about Neck. — Search should be made to discover whether the 
cord encircles the neck, and if it does a loop should be enlarged and drawn over 
the head; but if this cannot be done, the funis should be cut between a double 
ligature, or, if time is lacking, without the application of ligatures (Fig. 627). 

Delivery of the 
Shoulders. — After the 
head is born, in the ab- 
sence of any indication 
for immediate delivery, 
it is better to wait for 
natural expulsion of the 
shoulders and body, the 
head in the mean time 
being supported in the 
flat of the hand (Fig. 
628). 

Preservation of Peri- 
neum during Delivery of 
Shoulders. — This is best 
attained by preserving 
the normal mechanism 

of shoulder delivery (see page 498). Delivery of the shoulders should be delayed 
if possible until nearly complete rotation of the bisacromial diameter has taken 
place. The head should be held in the hand and gently raised so as to bring the 
anterior shoulder well up behind the symphysis, thus securing the cervico-acromial 
diameter of the fetus at the outlet instead of the bisacromial (Fig. 628). The 
posterior shoulder is thus permitted to be delivered first, contrary to the common 



\ 




Fig. 634. — Method of Cutting the Umbilical Cord after 
the Application of the Two Ligatures. 



THE MANAGEMENT OF LABOR. 



539 



custom, and should be carefully guided in its passage over the perineum. Shoulder 
delivery should be accomplished whenever possible by the natural forces, since I 





Fig. 635. — Method of Inspecting the 
Stump of the Umbilical Cord for 
Hemorrhage. 



Fig. 636. — Method of Instilling Drops 
of Nitrate of Silver Solution into 
the Eye of the Newly Born Child. 








Fig. 637. — Method of Lifting the Newly Born Child with One Hand. — {From a 
photograph taken at the Emergency Hospital.) 



540 



PHYSIOLOGICAL LABOR. 



have found that manual extraction increases the number of perineal lacerations. 
Care should be taken lest during the delivery of the shoulders an existing lacer- 
ation caused hy the head be increased in size. During the detention of the an- 
terior shoulder behind the pubis the fetal hand of the opposite arm lying across 
the child's chest will usually soon appear in the vulva. Delivery, we have found, 
is assisted by slowly flexing this forearm and arm out through the vulva and thus 
delivering the posterior shoulder by slight traction on the posterior arm. Should 
there be delay in the expulsion of the posterior shoulder, traction upward upon 
the head, the fingers encircling the neck, is to be preferred to traction with a 
finger in the axilla. (See Part X.) Should there be delay in the delivery of the 
anterior shoulder, it is best remedied by making traction directly downward 
with the hands placed on the sides of the head, taking care not to injure the peri- 




Fig. 63S. — Method of Lifting the Newly Borx Child with Two Haxds. — {From a 
photograph taken at the Emergency Hospital.) 



neum. If this does not succeed, traction may be made bv a finger in the axilla. 
(See Part X.) 

Delivery of Body, Pressure on Fundus. — After delivery of the shoulders the 
bod}^ is, as a rule, rapidly expelled. Should there be delay, however, the thorax 
may be grasped with the hands and gentle traction made, or, better, the fetus 
expelled by pressure upon the fundus. In the delivery of the shoulders and 
body of the fetus the general principle — namely, to make use of all the available 
space of the pubic arch — is followed. To accomplish this, the shoulders and body 
are not permitted to press too closely against the perineum, but are rather pushed 
carefully into the pubic arch. During the expulsion of the fetus the fundus is 
followed down by the hand of the physician or assistant, and must be watched 
for at least an hour. This duty may be relegated to an assistant or a nurse. 

Care and Posture of the Child in Bed. — If the child cries visrorouslv, measures 



THE MANAGEMENT OF LABOR. 



541 



for establishing respiration are unnecessary, and all rough handling should be 
avoided. It should be wrapped in a warm blanket previously prepared and 
allowed to rest between 
the mother's thighs until 
after ligation of the cord 
(Fig. 631). It should be 
placed upon the right 
side, since this posture 
tends to aid the physio- 
logical changes in the 
fetal circulation, and 
with head low to prevent 
cerebral anemia. 

Establishment of 
Respiration. — Should 
the child cry out feebly, 
or should there be any de- 
lay in the establishment 
of respiration, it should 
be smartly slapped upon 
the buttocks or a few 
drops of cold water 
should be dashed upon 
the face and chest. In 
feeble or premature chil- 
dren, however, all rough 
handling should be 
avoided. (See Asphyxia 
Neonatorum, Part IX.) 

Ligation of the Cord. — Respiration being fully established, the ligation of 
the cord should be delayed until pulsations cease, unless there is some positive 
indication to the contrary. Immediate ligation deprives the fetus of about 




Fig. 639. — Method of Inspecting the Lower Vagina 
and Perineum for Lacerations at the Completion of 
Labor. 




Fig. 640. — Testing the Amount of Injury to the Perineum. 



three ounces of blood. Before ligation it is a good plan to grasp the cord with 
the thumb and first finger of one hand close to the navel, care being taken not to 
make traction, and with the fingers of the free hand to strip away the gelatin 



542 



PHYSIOLOGICAL LABOR. 



of Wharton from the fetus for a distance of two or three inches (Fig. 632). This 
gives a thin stump for subsequent separation. The cord is now ligated with 
sterile bobbin or floss silk, about i\ inches from the umbilicus, it being first 
determined that no lesion of the cord exists. A second ligature is then placed 
about two inches from the first in order to prevent hemorrhage in case of twins, 
but chiefly to retain blood in the placenta that the uterus may more readily expel 
it. Division of the cord with scissors is now performed close to the first ligature. 
This is best done in the hollow of the hand, the scissors being passed between 
the second and third fingers to avoid injury to the actively moving extremities and 
unnecessary spurting of blood (Fig. 634). Some amputate the cord close to the 
umbilicus and bring the edges together with fine sutures (Dickinson). I have 
been unable to determine that this procedure possesses any advantages over the 
ordinary method. The stump of the cord is now touched with sublimate solu- 
tion (1 : 2000) and a dry occlusion dressing of absorbent cotton or gauze is ap- 
plied (Fig. 635). 

Care of Child. — The child, wrapped in some warm material, is placed upon its 

right side with its head lower than its body in 
some safe spot where it will not be liable to fall 
to the floor on the one hand, or be sat upon on 
the other. In lifting a naked, slippery child from 
the bed to wrap it in a blanket one may grasp it 
as in Fig. 637 by one hand, or with two hands, 
as in Fig. 638. In both instances the head in 
a state of flexion should be allowed to hang 
lower than the body. Either of these methods 
is recommended for physiological reasons. 

Prevention of Ophthalmia. — As soon after 
birth as convenient the eyes and lids are again 
wiped clear of mucus and 2 drops of a 2 per 
cent, solution of nitrate of silver are dropped 
into each eye (Fig. 636). This is strongly 
advised both in private and hospital practice. 

Inspection and Repair of Perineum (Fig. 
639). — Immediately after the completion of 
the second stage the patient should be care- 
fully turned over from the lateral to the dorsal 
posture to avoid air embolus. I am accus- 
tomed to inspect and, if necessary, repair the perineum at this time instead of 
waiting for the completion of the third stage. My reason for this is that it can 
be more readily done now on account of the partial anesthesia of the second 
stage, which can easily be prolonged if it be found necessary to insert ligatures. 
A little care in the delivery of the placenta will prevent undue traction upon the 
stitches during the third stage. The perineum and vagina should be carefully 
examined, as many severe lacerations are not visible externally. The labia are 
separated by the fingers wrapped in sterile gauze or cotton, both hands being 
used, and the parts thoroughly inspected. Here as elsewhere, however, intra- 
rectal manipulations are to be avoided if possible. The occurrence of rather 
free hemorrhage during the latter part of the second stage may indicate a vaginal 
laceration. 

Preliminary Vulval Dressing (Fig. 641). — Immediately after the expulsion 
of the child, I am accustomed to place over the gaping vulva an antiseptic 
dressing, either several folds of aseptic gauze or one of the aseptic vulval pads in 




Fig. 641. — Temporary Vulval 
Dressing of Sterile Gauze 
during the third stage of 
Labor. 



THE MANAGEMENT OF LABOR. 543 

common use. This dressing is allowed to remain in situ until the placenta 
displaces it on the delivery of the latter. This dressing I use with two objects 
in view: first, to prevent, as far as possible, the entrance of air into the gap- 
ing vagina; and, second, to indicate the amount of hemorrhage going on at 
this period. 



MANAGEMENT OF THE THIRD STAGE OF LABOR. 

The third stage of labor commences at the complete expulsion of the fetus or 
fetuses and ends at the complete expulsion of the placenta and membranes. The 
patient having been carefully assisted in turning from the lateral to the dorsal 
posture, the physician or nurse continues by gentle pressure, not kneading, of the 
fundus to keep up and encourage firm tonic uterine contractions in order to pre- 
vent hemorrhage and the formation of an intrauterine clot. When the uterus does 
not seem to be doing its work properly, it may be necessary to use gentle friction 
by a circular motion with the hand until contractions are resumed, or it may 
even be necessary to grasp the fundus vigorously and subject it to active manipu- 
lation in order to get a prompt response. There is generally a tendency to 
hasten the completion of the third stage. This should be avoided, and the 
temporary suspension of strong uterine contractions after the expulsion of the 
child should be looked upon as a physiological condition. Common mistakes 
at this time are : ( i ) Undue haste and rough manipulation in the completion of 
the third stage. This is a common cause of retained placenta. (2) Premature 
attempts at expulsion. It should be delayed at least until about half an hour 
after the birth of the fetus unless previous separation occurs. (3) The neglect 
to assure one's self that the bladder is empty. (4) To press the uterus forward 
against the pubis instead of downward and backward, more in the axis of the 
pelvic outlet. (5) To excite contractions instead of waiting for the natural 
ones. The former method should be practised only in cases of hemorrhage or 
dangerous uterine inertia. (6) It is not necessary to twist the membranes into a 
rope, and sometimes they are torn in this way. If the membranes should tear, 
a piece of sterilized thread may be tied to the part projecting from the cervix. 
Traction upon the membranes should not be made. 

With the onset of the third stage of labor care as to asepsis should be re- 
doubled. Untold harm has been done by unnecessary interference at this time, 
and sepsis is often caused by irrational attempts at its prevention. After the 
second stage the vagina and cervix are full of abrasions and trifling lacerations 
which are of no consequence if let alone, but which offer a tempting field for the 
propagation of septic germs. In normal cases all manipulations within the 
vagina, and especially the introduction of the fingers, should be scrupulously 
avoided during and after the third stage of labor. 

Prevention of Hemorrhage and Delivery of Placenta and Membranes. — The 
chief objects at this time are (1) to secure good uterine contraction, (2) to pre- 
vent hemorrhage and to deliver the placenta and membranes intact. If, as fre- 
quently happens, the placenta follows the child into the vagina, it may be ex- 
pressed at any time. Usually, however, placental separation takes at least half 
an hour. For this period after the child is delivered the uterus should be kept 
under manual observation, and if the placenta and membranes are not expelled 
in that time, the Crede method may be resorted to (Figs. 642 and 643). 

Crede's Method of Placental Expression. — To practise this the fundus is 
grasped with one hand, fingers behind and thumb in front, and a contraction 
awaited (Fig. 644). At the height of the pain the uterus is firmly compressed 



544 



PHYSIOLOGICAL LABOR. 



and forced downward and backward into the pelvis. If the first attempt fail, 
another may be made in the same manner at the next contraction. It may be 
necessary to repeat this procedure during several contractions. When the 
placenta appears at the vulva, little or no traction must be made upon it, but 
the membranes loosened and expelled by compression of the fundus of the 
uterus, at the same time pushing the uterus backward as nearly into the axis of 

the vagina as possible; the 
placenta meanwhile is allowed 
to rest in the palm of the other 
hand so that no unnecessary 
traction shall be made on the 
membranes (Fig. 643). The 




Fig. 642. — Delivery of the Placenta. The Left Hand follows down the Fundus 
of the Uterus and the Right Hand Receives the Placenta, the Latter Pre- 
venting any Sudden Tension upon the After-coming Membranes. The placenta 
is here expelled by Schultze's mechanism. — {From a photograph taken at the Emergency 
Hospital.) 



last string of membrane should be rather squeezed out than drawn out. After 
delivery of the placenta and membranes the physician continues to hold the 
fundus in the hand; this should be done for an hour after delivery (Fig. 642). 
An assistant or a nurse may relieve the physician of this duty. (See Operations, 
Part X.) 

Examination of the Placenta and Membranes (Fig. 633). — The physician now 
takes the placenta, turns the membranes back, and places the fetal surface down 



THE MANAGEMENT OF LABOR. 



545 



on the palm of his hand. The cotyledons should lie in close apposition; there 
should be no defect on the uterine surface at the furrows limiting the cotyledons, 
or at the margin of the placenta; the grayish- white coating of the decidua sero- 
tina should cover the cotyledons and no red placental villous tissue should be 
seen. He examines the margin of the placenta for torn vessels pointing to the 
retention of the secondary placenta or placenta succenturiata. Then he passes 
the hand into the cavity of the membranes, distends them, and, taking into 




Fig. 643. — Delivery of the Placenta. The Delivered Placenta is Supported in 
the Right Hand and the Left Hand Makes Moderate Pressure upon the Fundus 
of the Uterus until the Membranes are Loosened and Expelled. — (From a 
photograph taken at the Emergency Hospital.) 



account the size of the child and the amount of liquor amnii, estimates as 
nearly as possible whether the entire bag of membranes be present. 

Retention of Secundines. — Retained fragments of placenta are best removed 
immediately by passing two fingers into the vagina and os uteri, and with the 
external hand pressing the fundus down over the internal fingers which grasp and 
remove the fragments. Dangers of subsequent hemorrhage and sapremic in- 
fection are thus avoided. When uncertainty exists regarding the retention of 
small pieces of membrane, one can safely adopt an expectant plan of treatment, 
as in this case it is safer than intrauterine manipulations. The proposed routine 
uterine and vaginal examinations of the genital tract at this time to determine 
35 



546 



PHYSIOLOGICAL LABOR, 



the condition of the parts and the retention of secundines cannot be too vigor- 
ously condemned. Nothing is to be gained by this course save in very excep- 




Fig. 644. — Crede's Method of Placental Expression. — (The upper illustration is from 
a photograph taken at the Emergency Hospital.) 



tional cases, and as its routine practice involves a distinct element of risk, its 
adoption cannot be recommended. 



THE MANAGEMENT OF LABOR. 



547 



Ergot. — If the retraction of the uterus should not be entirely satisfactory after 
it is emptied, and manipulations and the Crede method have not induced contrac- 
tions, fluid extract of ergot may be given by the mouth or subcutaneously. The 
usual dose is one-half to one drachm by the mouth and twenty minims hypo- 
dermically; it may be repeated if required. This drug is especially useful after 
chloroform anesthesia, since the uterus sometimes does not contract quite 
promptly after its employment. Ergot used after the uterus is empty is useful 
as a preventive not only of hemorrhage, especially in multiparas and atonic cases, 
but of sepsis, and as an aid to involution and in the prevention of after-pains. 
The contraction of the uterine muscle 
keeps the sinuses closed, preventing 
the formation of clots and the en- 
trance of sepsis, and also hastens in- 
volution by curtailing the blood-sup- 
ply to the uterine muscular tissue. On 
the one hand, I know of no valid ob- 
jection to the use of one or two doses 
of ergot after confinement ; and, on the 
other, the drug thus used adds materi- 
ally to the safety and comfort of the 
patient. 

Post-partum Douche. — There is at 
present some controversy as to the ad- 
visability of giving a vaginal douche 
after delivery of the placenta. The 
analogy between the indications for 
the ante-partum and the post-partum 
douche is not, as some have supposed, 
perfect. Before delivery the vaginal 
mucous membrane is intact and 
bathed in the acid bactericidal mucus 
of the vagina. Hence, as Kronig has 
shown experimentally, ante-partum 
douches, by diluting and washing 
away this mucus, actually delay the 
destruction of pathogenic germs pre- 
viously introduced into the vagina. 
After delivery the conditions are quite 
different and all conditions for the 
propagation of sepsis are present. 
Hence it seems proper that one 
thorough vaginal douche should be 
given. Nothing but a glass tube 





Fig. 645. — -Inspection of Placenta and 
Membranes immediately after the 
Third Stage. Hand is Passed into Am- 
niotic Cavity and same Distended while 
Inspecting the Cotyledons of the Pla- 
centa. — (From a fresh specimen.) 



should be used, 



and this should be 
perforated at the sides, the perforations looking a little backward, that 
the fluid may not enter the uterus. As the tube is introduced the labia 
should be carefully separated. (See Part X.) and the tube carried as far as 
possible into the vagina without touching the surrounding tissues. When 
few or no vaginal examinations have been made, the post-partum douche 
should be omitted. It may be said to carry a risk of infection with it, but 
not to the same extent as the digital vaginal examination (Figs. 196 and 
197). In intelligent hands the irrigation is practically free from danger. It 
certainly, in my experience, adds to the comfort and safety of the patient by: 



548 PHYSIOLOGICAL LABOR. 

(i) causing the uterus and vagina to expel retained clots; (2) setting up firm 
uterine contraction which prevents hemorrhage and after-pains; (3) the warmth 
lessens the pain of the laceration and stretching to which the vagina has been 
subjected. An intrauterine douche is given only when the hand or instruments 
have been introduced into the uterus, or when there is other reason to suspect 
the possibility of intrauterine sepsis. 

Cleansing of the Patient and Bed. — At the completion of the third stage the 
external genitals should be carefully cleansed with boiled water and with bichlo- 
ride solution (1 : 4000); the cleansing should include the thighs, buttocks, and 
lower surface of the abdomen, since these are usually soiled by blood, perhaps 
by urine and feces. The temporary bedding should be removed and its place 
supplied by that which is perfectly clean, and the patient should, if necessary, 
have a clean night-dress. 

Vulval Dressing. — A sterile napkin, preferably an antiseptic pad of some 
absorbent material, should be applied to the vulva and held in position by a 
band carried between the thighs and fastened anteriorly and posteriorly to the 
abdominal binder by safety-pins. This vulval dressing should be changed as 
often as it becomes soiled. Deodorizing chemicals or those with any odor 
should not be used on the vulval dressing, as these mask the fetor of decompos- 
ing lochia, a valuable sign of early septic infection. 

Abdominal Binder. — This contributes to the comfort of the patient and is 
usually desirable. It should be of unbleached muslin and wide enough to reach 
from below the trochanters to the lower ribs. The attendant should stand on 
the patient's right and the binder should be fastened from below upward. This 
should be done by taking the part of the binder next to the abdomen in the left 
hand and the part which is to be external in the right and holding them together 
with one hand while the pins are inserted from below upward with the right 
hand. A moderately tight abdominal binder promotes involution of the uterus. 
After a few days it may be applied more loosely, and may be discarded when 
the patient leaves her bed. (See Part VI.) 

Presence of the Physician. — The physician should be within call for at least 
an hour after the completion of the third stage, and should not leave his patient 
until good uterine contraction has been secured and her pulse has become nor- 
mal, or is at least below 100. 

Nourishment, Rest, and Sleep. — When the third stage has been completed 
and the patient made comfortable, she should receive some light nourishment, 
as a cup of milk, weak tea, chocolate, cocoa, or soup. All visitors should be 
banished from the lying-in chamber; the curtains should be drawn, the room 
well ventilated, and the patient allowed to secure as much sleep as possible, 
undisturbed by the washing, dressing, or crying of the child . 



PART FIVE. 

Pathological Labor< 



DUE TO ABNORMAL CONDITIONS OF THE FETUS: FETAL 

DYSTOCIA. 

FETAL DYSTOCIA FROM FAULTY ATTITUDE. I. Excessive Flexion of Head. 
Roederer's Obliquity. II. Bregma Presentation. Incomplete Flexion. 
III. Brow Presentation. IY. Face Presentation. Y. Presentation of 
Anterior Parietal Bone or Ear. Naegele's Obliquity. YI. Presentation 
of Posterior Parietal Bone or Ear. Litzmann's Obliquity. VII. Prolapse 
of the Arms. Dorsal Displacement of the Arm. VIII. Prolapse of the 
Leg. IX. Prolapse of the Cord. 

FETAL DYSTOCIA FROM FAULTY PRESENTATION. X. Pelvic Presentation. 
XI. Shoulder Presentation. 

FETAL DYSTOCIA FROM FAULTY POSITION. XII. Persistent Occipito- 
Posterior Position. XIII. Persistent Mento=posterior Position. XIV. 
Transverse Engagement of Head in Inlet in Deformed Pelvis. XV. Trans= 
verse Position of Head at Outlet. 

FETAL DYSTOCIA FROM GENERAL FETAL CONDITIONS. XVI. Multiple 
Birth. XVII. Multiple or Compound Presentations. XVIII. Exces= 
sively Long Cord. XIX. Short Cord. XX. Rupture of the Cord. XXI. 
Decapitation of the Fetus. XXII. Avulsion of Fetal Extremities. XXIII. 
Malformations, Deformities, and Anomalies Producing Dystocia. XXIV. 
Fetal Rigor Mortis. 

DUE TO ABNORMAL CONDITIONS IN THE MOTHER: MA- 
TERNAL DYSTOCIA. 

MATERNAL DYSTOCIA FROM THE FORCES. I. Precipitate Labor. II. 
Protracted or Retarded Labor. Uterine and Abdominal Inertia. 

MATERNAL DYSTOCIA IN THE PARTURIENT TRACT AND ADNEXA. III. 
Retention of Placenta and Membranes. IV. Post=partum Hemorrhage. 
V. Rupture of the Uterus. VI. Inversion of the Uterus. VII. Excessive 
Right Lateral Obliquity of Uterus. VIII. Rupture of Cervix, Vagina, 
Rectum, Perineum. IX. Labor after Anterior Fixation or Suspension 
of Uterus. 

MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. X. Uterine, Ovarian, 
Renal, Peritoneal Tumors. XI. Anomalies of the Membranes. XII. 
Rigidity of the External and the Internal Os. Trismus Uteri. XIII. Devi= 
ation or Malposition of the Os. XIV. Occlusion of the External Os. 
XV. Cancer of the Uterus. XVI. Rigidity and Atresia of the Vagina 
and Vulva. XVII. Vaginal and Vulval Thrombosis and (Edema. XVIII. 
Distended Bladder and Rectum. Cystocele, Rectocele, Vesical Calculus. 
XIX. Fractures of the Pelvis. XX. Diastasis of Pelvic Joints. XXI. 
Pelvic Deformity. 

MATERNAL DYSTOCIA FROM GENERAL MATERNAL CONDITIONS. XXII. 
Labor in Elderly Primiparae. XXIII. Intestinal Hernias. XXIV. Cardiac 
and Pulmonary Disease. XXV. Cerebral and Spinal Disease. XXVI. 
Digestive Disturbances. XXVII. Sudden Death. XXVIII. Post=mortem 
Delivery. XXIX. The Metrorrhagia of Labor. 



Pathological labor or dystocia — the latter term from two Greek words 
meaning difficult or painful labor — is one which departs from the conditions of 
physiological labor, as set forth on page 423. A multitude of variations, acci- 
dental and pathological, may arise on the part of the mother or the fetus to 
cause this variety of labor. Originating in the latter they cause fetal dystocia, 
and in the former maternal dystocia. 

According to my classification I shall describe fetal dystocia as due to: 
(1) faulty attitude; (2) faulty presentation; (3) faulty position; and (4) general 
fetal conditions. Maternal dystocia I divide into dystocia from (1) the 
forces; (2) the parturient tract and adnexa; (3) obstructed labor; (4) general 
maternal conditions. 



DUE TO ABNORMAL CONDITIONS OF THE FETUS: 

FETAL DYSTOCIA. 

FETAL DYSTOCIA FROM FAULTY ATTITUDE. 

Faulty attitude or posture of the fetus may be caused by anything which 
alters the normal shape of the fetal ovoid (see page 469). Thus, dystocia may 
be due to a faulty attitude caused by any deviation of the fetal head from the 
normal position of flexion. According to the degree of extension present will 
be the variety of the malpresentation which will result. (1) Thus, occa- 
sionally excessive flexion (Fig. 646), or Roederer's obliquity, under certain 
conditions may act as a cause of fetal dystocia. (2) If the flexion is incomplete 
to a slight degree only, so that the chin departs only a short distance from the 
sternum, the bregma will present instead of the vertex and a bregma presentation 
results. (3) If a greater degree of extension occurs and the head occupies a 
position upon its transverse axis, midway between flexion and extension, the 
brow or the region immediately in front of the bregma will present, giving a 
brow presentation. (4) And if complete extension take place and the chin is 
the presenting part, a face presentation results. (5) Further, should lateral 
flexion of the head occur so as to cause the anterior parietal bone or the ear to 
present, the condition known as Naegele's obliquity occurs. (6) Should the 
lateral flexion result in presentation of the posterior parietal bone or the ear, 
the obliquity is called Litzmann's. Fault} 7 attitude may also result in prolapse 
of the (7) arms, (8) legs, (9) umbilical cord. 

I. EXCESSIVE FLEXION OF THE HEAD; ROEDERER'S OBLIQUITY. 

Excessive flexion of the head upon the trunk has been termed Roederer's 
obliquity (Fig. 646). This is nothing more than an exaggeration of the normal 
head flexion of labor whereby the occiput enters the inlet perpendicularly, the 

551 



552 



PATHOLOGICAL LABOR. 



EXCESSIVE FLEXION OF HEAD 
ROEDERER'S OBLIQUITY. 



head moulding being more to the posterior part of the head, with the apex well 
back on the occipital bone, thus positively providing for the engagement of the 
suboccipito-bregmatic circumference, n inches (28 cm.), in the circumference 
of the inlet, 16 inches (40.5 cm.), and is to be looked upon as a favorable condi- 
tion. The causes are excessive rigidity of the cervix or vagina, generally con- 
tracted pelvic inlets, or excessively large 
fetal heads, especially in dead or macer- 
ated fetuses. The diagnosis is simple. In 
left positions of the head the small fon- 
tanelle is more to the right and very little 
of the sagittal suture can be felt; the large 
fontanelle is unusually high. The prognosis 
is not necessarily favorable at the pelvic 
inlet, although after the engagement of the 
head the conditions never cause dystocia. 
Because of the obstruction sometimes pro- 
duced at the inlet by excessive flexion of a 
large head of a dead or macerated fetus, 
causing the shoulders and head to attempt 
to enter at the same time, I have classed 
this condition among the causes of fetal 
dystocia. Many authorities refer to the 
condition only under normal labor. Treat- 
ment may be demanded at the inlet to 
assist in the engagement of the head, since 
the tonicity of the neck has been lost in 
macerated fetuses. After engagement no 
treatment is required. 







Fig. 646.- 



-occiput at 
Inlet. 



the Pelvic 




II. BREGMA PRESENTATION.* 
COMPLETE FLEXION. 



IN- 



Fig. 647. — Occiput at the Pelvic 
Inlet. 



Definition. — By this condition is meant 
a partial extension of the head whereby 
the large fontanelle is brought upon the 
same plane as the small (Fig. 649). 

Frequency. — Authorities generally state 
that incomplete flexion resulting in a 
bregma presentation is rare. My experi- 
ence is that dystocia from this source is 
most common. I believe it to be one of 
the most important factors in the produc- 
tion of prolonged and tedious labors, either 
from tardiness in the rotation from a pos- 
terior to an anterior position due to the 
incomplete flexion, or because the occipto- 
frontal circumference (13I inches — 35 cm.) 
instead of the suboccipito-bregmatic (11 inches — 28 cm.) is brought in rela- 
tion to the periphery of the birth canal. 

Temporary and Persistent Varieties. — A close observer cannot fail to detect 
instances in which incomplete flexion of the head or bregma presentation has- 
* The bregma is the anterior fontanelle. 




Fig. 648.- 



■Occipital Bone in the 
Cervix. 



FETAL DYSTOCIA FROM FAULTY ATTITUDE. 



553 



BREGMA PRESENTATION OR IN- 
COMPLETE FLEXION OF 
THE HEAD. 

VERTEX TO THE LEFT. 




occurred both as a temporary and as a persistent condition. Temporary descent 
of the large fontanelle is frequently observed in all the four positions of the vertex 
in normal labors during the engagement of the head in the inlet, but more fre- 
quently in roomy pelves after the head has 
passed the psoas muscles and entered the 
roomier part of the pelvis, also in slightly 
and decidedly flattened pelves in conjunc- 
tion with Naegele's lateral flexion and 
presentation of the anterior parietal bone. 
In the case of flattened pelves the biparie- 
tal diameter becomes arrested at the con- 
tracted inlet, the narrower bitemporal 
diameter of the sinciput descends, engages, 
and passes the inlet, followed, after a 
period of moulding, by the biparietal and 
restitution of the head to its normal state 
of complete flexion. In the persistent 
variety, although the same etiological fac- 
tors may obtain, still for some reason the 
condition .becomes permanent. 

Etiology. — This is the same as in brow 
and face presentations, although in some 
instances dolichocephalic conditions of the 
fetal head play an important part (pages 
555 and 561). 

Positions and Relative Frequency. — 
The positions and their relative frequency 
are the same as in vertex presentations, 
as the anatomical conditions differ very 
little from those of normal labor. 

Mechanism. — While some authorities 
consider that bregma presentation demands 
a description of a special mechanism, I am 
accustomed to describe the condition as 
merely a departure from the mechanism of 
vertex presentation due to moderately 
incomplete flexion of the head. The me- 
chanism differs from that of normal vertex 
presentation in that departure from the 
normal occurs by reason of the increased 
circumference of the presenting part, and, 
further, the imperfect flexion brings the 
forehead down as far as the vertex, thus 
interfering with internal anterior rotation. 
It must be remembered that labor is not 
impossible in all cases of this condition, 
and that the several steps in the mechanism 
can be recognized as in other presenta- 
tions. Should the partial extension be uncorrected, the mechanism is as 
follows: Moulding is extensive by reason of the delay. Since the occipito- 
frontal diameter (4.5 inches — 11.50 cm.) and circumference (13 | inches — 35 
cm.), and not the suboccipito-bregmatic diameter (3! inches — 9.5 cm.) and 



Fig. 649. 



-Bregma at 
Inlet. 



the Pelvic 




Fig. 



650. — Bregma at 

IXLET. 



the Pelvic 




Fig. 651. — In the Cervix: Right 
Parietal Bone and Half of 
Frontal Presenting. 



554 



PATHOLOGICAL LABOR. 



BREGMA PRESENTATION OR INCOM- 
PLETE FLEXION OF THE HEAD. 

VERTEX TO THE RIGHT. 



\ ; 




. J 



Fig. 652. — Bregma at the Pelvic Inlet. 




Fig. 653. — Bregma at the Pelvic Inle' 



/ r== ^\ 




Fig. 654. — In the Cervix: Left Parie- 
tal Bone and Half of Frontal Pre- 
senting. 




Fig. 655. — At the Pelvic Floor. 



circumference (11 inches — 28 cm.), are 
brought in relation with the diameters 
and circumference of the pelvic inlet, 
persistent bregma presentations undergo 
prolonged and characteristic moulding 
(Fig. 657). Engagement and descent are 
slow by reason of the greater circumfer- 
ence involved; rotation of the head fails 
altogether because the vertex and fore- 
head are equally influenced by the factors 
causing rotation, or is accomplished only 
with the greatest difficulty and much 
damage to the maternal soft parts. 
Labor often comes to a standstill by 
reason of the transverse position of the 
occipitofrontal diameter on the pelvic 
floor. The perineum begins to tear even 
before the head has reached it, on 
account of the great dilatation of the 
upper vagina by the large cephalic 
diameters. The laceration becomes ex- 
tensive, extending through the sphincter 
ani and even up the recto-vaginal sep- 
tum. In expulsion of the head the 
latter is born by propulsion and partial 
extension. Rotation and delivery of 
the trunk occur as in normal labor. 

Diagnosis. — This is not difficult. 
Whenever on vaginal examination the 
large fontanelle is readily made out as 
occupying a prominent place in the cir- 
cumference of the parturient canal with 
the sagittal, frontal, and coronal sutures 
radiating therefrom, the condition may 
be looked upon as one of bregma presen- 
tation or incomplete flexion of the head. 
This presentation in its clinical features 
resembles a brow, as the supraorbital 
ridges may often be palpated well up 
anteriorly, posteriorly, or laterally. 
(Figs. 654 and 650.) 

Prognosis. — This is usually good, as 
the condition is readily recognized and 
remedied. When overlooked, all the 
dangers of tedious labor and secondary 
inertia are to be feared. 

Treatment. — Immediate correction of 
the incomplete flexion should be per- 
formed either (1) by pushing the fore- 
head up during uterine contraction with 
two fingers in the vagina, at the same 
time making pressure upon the fundus; 



FETAL DYSTOCIA FROM FAULTY ATTITUDE. 



555 



MOULDING OF HEAD IN BREGMA 
PRESENTATION. 




Fig. 6=56. — Before Moulding. 



or (2) the whole hand may be introduced into the vagina and either the occiput 
drawn down or the forehead pushed up, counterpressure being at the same time 
made upon the podalic extremity of the 
fetus through the fundus, or upon the 
occiput through the lower uterine seg- 
ment. (See Correction of Bregma, 
Brow, and Face Presentations, Part X.) 

III. BROW PRESENTATION. 

Definition. — A partial extension of 
the head whereby the brow instead of 
the vertex becomes the presenting part. 
The head is so extended in this presen- 
tation as to occupy a position midway 
between complete flexion and complete 
extension (Fig. 658). 

Frequency. — This is the rarest of all 
cephalic presentations and occurs in 
one-fourth of one per cent, of all cases. 
As brow presentation is a transition 
stage in the development of face pre- 
sentation, it is, considered temporarily, 
as frequent as the latter. But as 
generally estimated — those which re- 
main brow till artificially altered — they 
are far less common than the face. In 
a series of 2200 consecutive confine- 
ments I found brow presentation in 3 
cases, or 0.13 per cent., or 1 in 733 cases. 
Face presentation occurred in 5 cases, or 
0.22 per cent., in the same series. 

Etiology. — Any cause which favors 
incomplete flexion or partial extension 
of the head may cause a brow presenta- 
tion; the causes are, therefore, the same 
as those for face presentation. (See page 
561.) If the brow is not converted by 
natural means into a face presentation, 
the inference must be drawn that there 
is a greater obstacle present than in 
cases in which face presentation de- 
velops. The forces exerted on the two 
arms of the head-lever in brow presenta- 
tion are almost equal, the posterior arm 
being just a little longer than the ante- 
rior (Fig. 656). 

Positions and Relative Frequency. — There are four cardinal positions of the 
brow, as in other presentations: 




After Moulding. 



I. Left fronto-anterior — Fronto Lasva Anterior — L. F. A. (Fig. 658). 
II. Right fronto-anterior — Fronto Dextra Anterior — R. F. A. 



556 



PATHOLOGICAL LABOR. 



FIRST BROW POSITION. 
Left Fronto-anterior, L. f. a. 




Fig. 658. — Brow at Pelvic Inlet. 



Fig. 



Cervix. 




v 



Fig. 660. — At Pelvic Floor before 
Anterior Rotation of Brow. 




Fig. 66 r. — In the Vulva after Ante- 
rior Rotation of the Brow. 



III. Right fronto-posterior — Fronto 
Dextra Posterior — R. F. P. 

IV. Left fronto-posterior — Fronto 
Laeva Posterior — L. F. P. (Fig. 662). 

As in vertex presentation, the third 
and first positions are the most frequent, 
and in the order named. 

Mechanism. — (1) Brow presentation, 
being often a transitional condition 
between vertex and face presentation, 
may at any stage in the mechanism of 
labor be converted into one of these 
spontaneously. (2) Again, with a roomy 
pelvis and a small fetus, the latter 
in brow presentation may be pushed 
through the pelvis without any special 
mechanism. (3) In exceptional cases 
in which the fetal head is relatively 
small, special mechanisms of brow pres- 
entation can be recognized, as follows: 

III. Right Fronto-posterior, R. 
F. P. — (1) Moulding: This process is 
so slow that sometimes labor pains 
continue for hours — twenty-four to 
thirty-six — before engagement of the 
brow takes place. In the unusual cases 
in which a brow presentation enters the 
pelvis, there has been an extreme mould- 
ing of the head, the latter being rather 
small; the caput succedaneum occupies 
the space from the root of the nose to 
the anterior fontanelle. A side view of 
the head shows it to be rather triangu- 
lar in shape. (See Figs. 667 and 668.) 
The occipito-mental diameter has de- 
creased, but this has been compensated 
for by an increase of the occipito-fron- 
tal. The shape of the head is now 
characteristic of this presentation. The 
slope of the parietal and occipital bones 
is downward and backward, while the 
forehead is almost perpendicular. (2) 
Engagement and Descent: Because of the 
altered shape of the head the forehead 
sinks into the pelvis more deeply than 
any other part of the head and the 
head is somewhat extended as it passes 
through the pelvic inlet. The course 
of the brow to the pelvic floor is 
due to energetic contractions of the 
uterus, causing the mother much pain. 



FETAL DYSTOCIA FROM FAULTY ATTITUDE. 



557 



Labor usually comes to a standstill at 
this stage of engagement and descent 
by reason of obstructed labor. (3) 
Anterior Rotation of the Forehead (Fig. 
664): If the presentation remains un- 
changed until expulsion, the forehead 
finally reaches the pelvic floor and 
rotates anteriorly for the same reasons 
as the occiput does in vertex presenta- 
tion. At the same time the vertex ro- 
tates posteriorly into the hollow of the 
sacrum. The brow lies opposite the 
vulva, the face just back of the pubis 
with the chin at its upper margin, and 
the superior maxilla against the sym- 
physis. Anterior rotation of the brow 
at the pelvic floor may, in exceptional 
cases, possibly occur, but more often 
labor comes to a standstill with a 
deep transverse position of the head. 
(4) Expulsion of the Head (Fig.- 665): 
Before the head has appeared outside 
the vulval orifice, the neck and the 
body of the child has descended some- 
what into the pelvis. The flexion of 
the head is increased as the forehead 
appears in the vulva; the perineum 
then retracting. Expulsion is accom- 
plished by the cranial vault first sweep- 
ing forward over the perineum ; then the 
eyes, nose, superior maxilla, mouth, and 
chin successively make their appearance 
under the symphysis pubis, and are 
born. (5) Rotation of the Trunk and 
Restitution of the Head (Figs. 661 and 
665) : After delivery of the head, shoulder 
rotation and restitution of the head 
occur as in vertex presentation. In 
the right fronto-posterior position the 
left shoulder rotates to the symphysis 
and restitution of the child's face to the 
left thigh occurs. (6) Expulsion of the 
Trunk: This is the same as in vertex 
and face presentations (page 498). 

I, II, and IV. Left Fronto-ante- 
rior, L. F. A.; Right Fronto-ante- 
rior, R. F. A.; and Left Fronto- 
posterior, L. F. P. (Fig. 662), follow 
the same general principles as the 
above. 

Permanent Posterior Rotation of the 
Brow. — As in permanent occipito-pos- 



FOURTH BROW POSITION. 
LEFT FRONTO-POSTERIOR, L. F. P. 




Fig. 662. — Brow at Pelvic Inlet. 




Fig. 663. — Forehead in the Cervix. 




Fig. 664. — Brow at the Pelvic Floor 
before Anterior Rotation of the 
Forehead. 




Fig. 665. — Delivery of the Head after 
Anterior Rotation of the Brow. 



558 



PATHOLOGICAL LABOR. 



terior and mentoposterior positions, arrest may occur at the pelvic inlet, or 
after engagement of the brow. As in face presentation with the chin posteriorly, 
the difficulties of spontaneous delivery are so great that birth may be said to be 
impossible unless anterior rotation of the brow occurs. 



Position of Fetus. 



Position of Fetal Heart 
Sounds. 



Left fronto-ante- 
rior. L. F. A. 

Right fronto-an- 
terior. R. F. A. 

Right fronto-pos- 
terior. R. F. P. 

Left fronto-pos- 
terior. L. F. P. 



Brow to left acetabulum; back to right; ex- 
tremities to left, above. 



Brow to right acetabulum; back to left; ex- 
tremities to right, above. 



Brow to right sacro-iliac joint; back to left: 
extremities to right, above. 



Brow to left sacro-iliac joint; back to right; 
extremities to left, above. 



Right side of abdomen, 
below umbilicus. 



Left side of abdomen, 
below umbilicus. 



Left side of abdomen, 
below umbilicus. 



Right side of abdomen, 
below umbilicus. 




Diagnosis. — By abdominal examination the two ends of the head may be 
discovered to be at about the same level (Fig. 662). Unless the subject is readily 
palpated, the diagnosis of a brow presentation by external palpation is very 

difficult. By vaginal ex- 
amination the small fon- 
tanelle and the orbital 
ridges are felt at opposite 
points in the available 
space, while the large fon- 
tanelle and the coronal, 
frontal, and sagittal sutures 
are between (Figs. 659 and 
663). 

Prognosis. — This is un- 
certain for the mother and 
very bad for the fetus. 
Maternal mortality is as 
high as 10 per cent.; fetal 
mortality has reached 30 
per cent. The dangers to 
the mother are exhaustion 
from prolonged labor due 
to obstruction, severe laceration of the parturient canal, sepsis, and shock. The 
dangers to the child are excessive moulding and compression of the skull, causing 
apoplexy or asphyxia; prolapse of the cord is a common complication, as in 
deformed pelves, because the brow imperfectly fits the pelvic inlet. The family 
must be warned that the child's face will be swollen and hideous as in face pres- 
entation. It is quite possible for spontaneous rectification of a brow presenta- 
tion to occur at any stage of the mechanism of labor. This, however, cannot be 
relied upon any more than in shoulder presentation.* Sometimes, though 

* Ahlfeld ("Die Entstehung Steiss- und Gesichtslagen ") furnishes twenty-six cases in 
which the result to both mother and child is given. Fritsch ("Klinik der alltaglichen 
geburtshulflichen Operationen," p. 46) gives the histories of seven cases, and Budin ("Tete 
du Foetus," p. 53) the history of one case. In the thirty-four deliveries there were two 
maternal deaths; in one of the fatal cases a coxalgic oblique pelvis existed as a complica- 
tion. In the other the brow spontaneously changed into a face presentation. There were 
ten spontaneous deliveries, the brow presenting with four dead children, but one died 
previous to labor. There were ten cases of spontaneous delivery in which the brow during 



1 



Fig. 666. 



-Persistent Posterior Position of the 
Brow. 



FETAL DYSTOCIA FROM FAULTY ATTITUDE. 



559 






rarely, if the fetus is very small, or 
the pelvis very large, the fetus may 
be delivered without any mechanism 
or danger. In reality the prognosis 
will depend on the operation which is 
chosen for delivery of the child. An 
unchanged brow position with normal 
head will require so much time for 
spontaneous delivery that the ob- 
stetrician cannot conscientiously wait 
for nature to complete the birth. 

Treatment. — One must never trust 
to spontaneous rectification ; manual 
correction of the faulty attitude into 
a vertex presentation, or even into a 
breech by podalic version, gives better 
results than waiting for spontaneous 
delivery with the brow presenting. 
Correction of a brow presentation by 
changing the posture of the woman. 
and also, I may add. by external 
manipulation alone, as in Schatz's 
method (Part X), are refinements of 
obstetric procedure which rarely suc- 
ceed and unnecessarily disturb the 
patient. Further, in this as in other 
faulty attitudes, presentations, or 
positions of the head when the fetus is 
positively determined to be dead, 



MOULDING IN BROW PRESENTATION. 




Fig. 667. — Before Moulding. 




Fig. 668. — Fetal Skull showing Mould- 
ing in Brow Presentation. — (Author's 
collection.) 




Fig. 669. 



-After Moulding in 
Anterior Position. 



Fronto- 



delivery became converted into either a face or a vertex presentation. Of these one child 
died. Fourteen children were extracted with forceps, nine with the brow presenting, of 
which two were dead, one from prolapsed funis, and one which had died before labor; five 
after conversion into face or vertex presentations, with no deaths. Thus among the thirty- 
four children there were seven deaths, but of these, four only could be attributed to the 
presentation. 



560 PATHOLOGICAL LABOR. 

perforation of the skull and extraction with the cranioclast or cephalotribe should 
always be performed when by so doing the prognosis for the mother is improved. 
Arguments from the standpoint of sentiment alone should never deter us from 
mutilating the head of a dead fetus in order to lessen the dangers of extracting 
an unmutilated head through the birth canal. 

i. Before Engagement of the Brow. — (i) Placing the parturient on the side 
toward which the dorsal plane of the fetus points, or an attempt at manual 
correction by external manipulation by Schatz's method (see Part. X), may 
be tried, but it offers little hope of success. (2) Manual conversion of the 
brow into a vertex by combined internal and external methods is the best 
treatment. Digital upward pressure on the brow; lifting up the brow with the 
whole hand; drawing down upon the occiput with the whole hand, or one of 
these methods combined with Schatz's method, and all combined with external 
manipulation, as described in Part X, should be tried, and in the order named. 
Flexion, once obtained, must be maintained until engagement takes place, other- 
wise the brow presentation will recur. These indications obtain at the pelvic 
inlet, in both fronto -anterior and fronto-posterior positions of the brow. Of 
course, the conversion of the former into a vertex presentation results in an 
occipito-posterior position at the inlet, but even this position of the vertex offers 
a better prognosis than a brow presentation. To extend the head manually 
in fronto -anterior positions and convert the brow presentation into a mento- 
anterior position of the face, is a most questionable procedure; and in view of 
the serious prognosis in face presentations, I would be unwilling to recommend 
it. Salowieff,* however, in 18 brow cases occurring in the Moscow Maternity 
Hospital during a period of ten years, found that 10 were terminated by version 
and expression, 1 by forceps, 1 spontaneously, 1 in a vertex presentation, and 
5 in face presentations. The last five were treated by introducing a finger into 
the child's mouth, drawing the chin toward the brow, and retaining the finger 
in the mouth until the uterine contractions fixed the head in the converted face 
presentation. Simplicity and safety are claimed for this procedure. The un- 
favorable prognosis of face presentation has, however, still to be met. (3) The 
forceps in a true brow presentation should never be resorted to before at least 
partial rectification of the faulty attitude, for the unusually large circumference 
of the presenting part results disastrously for the fetus and mother. (4) Fail- 
ing in manual rectification, one of the methods of version, followed promptly 
by extraction, offers the best prognosis, always provided the necessary con- 
ditions for version are present or can be secured (see Part X). 

2. After Engagement of the Head. — (1) An attempt at manual rectification 
as described above should be made. (2) The use of the forceps is dangerous 
and difficult, and must only be tentatively attempted. (3) Symphyseotomy, 
undoubtedly, in the presence of a living fetus, offers the only hope after manual 
rectification fails, and should be seriously considered. (4) In all instances in 
which the fetus is known to be dead, perforation of the head should be per- 
formed. 

IV. FACE PRESENTATION. 

Definition. — A face presentation may be defined as a cephalic presentation 
in which the head is in extreme extension, with the occiput in contact with the 
neck. The face engages in the pelvis with the chin as the most dependent por- 
tion. Face positions are therefore classified, in accordance with the location of 
the chin, as right and left mento-anterior and posterior (Figs. 671, 675, 679, 683). 
* " Centralbl. f. Gynak.,'' Leipzig, 1898, No. 30. 



FETAL DYSTOCIA FROM FAULTY ATTITUDE. 



561 



Frequency. — About i labor in 250 is a face presentation (0.5 per cent.)- 
This represents an average, as individual statistics show considerable variations. 
In 2200 cases of labor I found that face presentation occurred in 5 cases, or 0.22 
per cent., or 1 in 440 cases (compare Pelvic Deformity) (Fig. 670). 

Etiology. — At first sight face presentation appears to be a simple anomaly 
of the mechanism of labor, the result of some obstruction in the parturient tract 
which unflexes and extends the head. Regarded from this simple point of view,, 
a face presentation would be looked upon as a consequence of pelvic contraction,, 
and perhaps of rigid os, prominent ischial spine, and the like. But this assump- 
tion is by no means easy of demonstration, nor is there any necessary ratio 
between the frequency of particular types of obstruction of the birth tract and 
deflexion anomalies. Some other factors must contribute to its production. 
Both observation and theory point to the possibility that anomalies in the fetal 
head or neck are often concerned in the production of this presentation. Some 
of the conditions which reside in the fetus and interfere with normal flexion are : 
congenital goitre, spastic 
contraction of the muscles 
of the neck, coiling of the 
cord about the neck, etc. 
But conditions of this sort 
occur with too great infre- 
quency to account for the 
production of face presen- 
tation. Moreover, the fac- 
tors thus far enumerated 
do not account for all the 
face births encountered in 
practice, or even, accord- 
ing to some authorities, for 
the majority of them. We 
have to look upon face 
presentation as something 
more than an anomaly of 
the mechanism of labor ; or, 
in other words, it must be 
placed in the same cate- 
gory with breech and shoul- 
der presentations. From this point of view we are able to add to our etiological 
factors the causes of malposition in general; including prematurity, contracted 
pelvis, hydramnios, multiple pregnancy, monstrosities, etc. These, however, 
cannot be brought into direct relationship with the effects produced, and 
the connection between the two is a matter of statistics rather than of 
actual demonstration. It is evident that we must look still more deeply 
into the matter before we can exhaust all possible etiological factors. Only- 
one element remains for consideration, viz., the uterus itself. Matthews Duncan 
was able to trace a relation between lateral deviation of the uterus and certain, 
face 'births; and other authorities have similarly held the triangular and 
saddle-shaped types of uterus responsible for the latter in certain cases. The 
individual causal elements which are at present recognized by most authorities, 
may be divided as follows: (1) Causes of malposition in general, such as pre- 
maturity, contracted pelves, hydramnios, twin pregnancy, monstrosities, etc.,. 
and the conditions covered by Schatz's hypothesis. (2) Causes residing. 
36 




Fig. 



670. — Diagram showing the Frequency of Face 
Positions. 



562 



PATHOLOGICAL LABOR. 



FIRST FACE POSITION. 
Left mentoanterior, L. m. a. 




Fig. 671. — Face at Pelvic Inlet. 




Fig. 672. — Chin and Left Cheek in 
the Cervix. 




W*s 



N 



Fig. 673. — Face at Pelvic Floor 
before Anterior Rotation of the 
Chin. 




Fig. 674. — Face in the Vulva after 
Anterior Rotation of the Chin. — 
{Author's photograph.) 



in the uterus, such as lateral obliquity, tri- 
angular and saddle-shaped uteri, pendulous 
abdomen (Fig. 153), etc. (3) Causes resid- 
ing in the fetus which interfere with flexion 
or favor extension. These are numerous 
and varied and include: large head from 
any cause; long head; tumor of occiput; 
spastic rigidity of neck muscles — all of 
which produce extension; and congenital 
goitre, coils of cord under the chin; obesity 
and dropsical condition; muscular hypo- 
tonus of the asphyxiated and dead child — 
all of which prevent flexion. (4) Causes 
residing in the parturient canal: narrow 
pelvis, especially short transverse diameter ; 
rigid os; the projecting rim of a placenta 
praevia ; prominent ischial spine ; distended 
maternal bladder. 

Ahlfeld regards all causes resident in 
the uterus or fetus as primary, and all 
causes which obtain in the birth passages 
as secondary. In Winckel's cases, 30 
per cent, had hydramnios; 22 per cent. 
had coiling of the cord about the child; 30 
per cent, had contracted pelves, etc. The 
most frequent association in these cases, 
in Winckel's experience, is contracted pel- 
vis, large child, and pendulous abdomen. 

Position and Relative Frequency (Fig. 
670). 

I. Left mento-anterior, mento laeva 
anterior, L. M. A. (Fig. 671), 
second in frequency. 
II. Right mento-anterior, mento dex- 
tra anterior, R. M. A. (Fig. 675). 
Right mento-posterior, mento dex- 
tra posterior, R. M. P. (Fig. 
679), most frequent. 
Left mento-posterior, mento lseva 
posterior, L. M. P. (Fig. 683). 

The relative frequency of the several 
positions is, first, right mento-posterior; 
and, second, left mento-anterior. Right 
mento-anterior and left mento-posterior 
are very rarely seen. (Compare Presenta- 
tion, page 473, and Fig. 670.) 

Mechanism. — I. Left Mentoante- 
rior, L. M. A. (Fig. 671).— The part 
played by the occiput in vertex presen- 
tation is simulated by the chin in face 
presentation. Face presentation, how- 
ever, differs somewhat in the mechanism 



III. 



IV. 



FETAL DYSTOCIA FROM FAULTY ATTITUDE. 



563 



of labor from vertex, although the same 
general principles obtain. The forces act 
at a disadvantage in face presentation, 
(i) The direction of uterine contraction 
is not in direct line with the lowest por- 
tion of the presenting part as in vertex 
presentation (Fig. 692). (2) The cervical 
Vertebrae, owing to extension of the head, 
are bent almost at right angles, hence the 
head is dragged rather than pushed through 
the pelvis, with a resulting tremendous 
friction, loss of x jower, prolonged labor, 
and dangerous compression of the vessels 
of the neck. (3) Again, in the internal 
rotation of the face another difficulty in 
the ordinary mechanism of labor presents 
itself. Anterior rotation of the chin does 
not occur so readily as anterior rotation of 
the vertex because the distance from the 
trunk to the chin is less than from the 
trunk to the occiput. The depth of the 
sides of the pelvis is 3^ inches (8.75 cm.) 
and the distance from the trunk to the 
chin in face presentations is about 2 inches 
(5 cm.), hence, either the neck must be 
elongated in order to allow the chin to 
reach the resistance of the pelvic floor or 
the shoulders and thorax must enter the 
pelvis with the face. The second is im- 
possible without causing impaction, and 
the first results in prolonged labor and 
danger to the fetus, hence interference is 
often called for in face presentations at 
the time of rotation of the chin anteriorly. 
Further, when the chin finally reaches the 
pelvic floor, the irregular, soft, often cede- 
matous chin is not acted upon so positively 
by the factors which produce anterior rota- 
tion as is the regular, hard vertex, and 
hence the tardy rotation of the face and 
greater necessity for instrumental inter- 
ference in this stage of the mechanism of 
labor in face presentation. (1) Extension 
and moulding of the head: The head passes 
through several stages of inclination before 
complete extension is reached, and the 
occiput lies close to the dorsum. During 
this process moulding takes place to a 
certain extent, though it is difficult of 
accomplishment and requires a long time. 
This is due to the mature ossification of 
the bones and sutures of the face. The 



SECOND FACE POSITION. 
Right Mentoanterior, R. M. a 




0^ 



Fig. 675. — Face at Pelvic Ixlet. 




Fig. 676. — Chin axd Right Cheek in 
the Cervix. — {From author's draw- 
ing.) 




Fig. 677. — Face at the Pelvic Floor 
Before Axterior Rotatiox of the 
Chix. 




Fig. 678. — Delivery of the Face 
after Anterior Rotation of the 
Chin. — {Author s photograph.) 



564 



PATHOLOGICAL LABOR. 



THIRD FACE POSITION. 
Right Mentoposterior, R. M. P. 




Fig. 679. — Face at Pelvic Inlet. 




Fig. 680. — Chin and Right Cheek in 
the Cervix. — {From author's draw- 
ing.) 




Fig. 681. — Face at the Pelvic Floor 
before Anterior Chin Rotation. 




Fig. 682. — Delivery of the Head 
after Anterior Rotation of the 
Chin. — {Author's photograph.) 



shape of the head after an ordinary face 
delivery presents a flattened vault, while 
the frontal bones are increased in their 
convexity and the supra-occipital is pressed 
back. (Figs. 688 and 689.) The diameter 
of the face occupying the right oblique 
diameter of the inlet is the cervico-breg- 
matic, and this is so long (3! inches — 9.5 
cm.) that it necessitates quite extensive 
moulding of the head, especially if the 
adaptation is inclined to be tight. The 
entire back of the head must be bent 
downward and pressed against the neck. 
(Fig. 688.) The anterior or left cheek is 
on a lower level than the posterior (Fig. 
672). In face presentations the cheek 
which comes first, or the anterior one, is 
the seat of the caput, and the size of the 
latter will be in accordance with the amount 
of time which elapses before anterior rota- 
tion of the chin occurs. Delay after rota- 
tion involves the entire face in the forma- 
tion of a caput. If there is no unusual 
delay in extension, the lower part of the 
face is exposed, while in case of delay the 
caput is formed at the upper portion of 
the face. (2) Engagement and descent of 
the face (Fig. 673): The chin is the main 
point of the mechanism, and it is so far 
ahead of the cervico-bregmatic diameter 
that it is deep in the pelvis by the time 
this diameter has passed the pelvic inlet. 
Here sometimes occurs a temporary stand- 
still for a time, for if the region of the 
sagittal suture remains in the sacro-iliac 
notch, the sacral promontory will prevent 
the head from turning backward, while all 
this, time the lower part of the anterior 
sulcus is imparting continually a forward 
impetus to the chin. The contractions of 
the uterus as well as extension of the neck 
of the fetus bring the fetal face to the floor 
of the pelvis. The extension of the fetal 
neck sometimes amounts to 2 inches (5 
cm.) before the chin and the pelvic floor 
are brought into contact. (3) Anterior 
rotation of the chin (Fig. 673): In order 
that anterior rotation of the chin may 
take place, the force of propulsion must 
be strong enough to press the chin 
down to the lowest point possible in 
the pelvis. After the occiput passes the 



FETAL DYSTOCIA FROM FAULTY ATTITUDE. 



565 



sacral promontory the chin rotates ante- 
riorly under the symphysis pubis, while 
the bregma sinks into the hollow of 
the sacrum. (4) Flexion and expulsion 
of the head (Figs. 674, 678, 682, 686): In- 
ternal rotation being partially or entirely 
•complete, the force of uterine contrac- 
tion causes the expulsion of the head by 
flexion; the chin, mouth, nose, eyes, and 
forehead appearing successively in the 
vulva. (5) Rotation of the trunk and 
restitution of the head: Following the 
same law as in vertex presentation (page 
498), the lower or left shoulder or ante- 
rior shoulder rotates to the symphysis, 
causing the child's face to turn to the 
mother's left thigh (restitution) (Fig. 686). 
(6) Expulsion of the trunk: This is the 
same as in vertex presentation (page 498, 
Fig. 583). 

II. Right Mento-anterior Position, 
R. M. A. (Fig. 675). — Here the same general 
principles obtain as regards (1) extension 
and moulding of the head and (2) engage- 
ment and descent, these being the same as 
in the left-mento anterior (Fig. 675). (3) 
Rotation of the chin is from right to left 
(Fig. 677). (4) Flexion and expulsion of 
the head are the same as in the L. M. A. 
(Fig. 678). (5) In rotation of the trunk 
and restitution of the head the right ante- 
rior or lower shoulder rotates anteriorly 
to the symphysis, and the consequent res- 
titution of the child's face is toward the 
right thigh of the mother (Fig. 682). (6) 
Expulsion of the body follows. 

III. Right Mento-posterior Posi- 
tion, R. M. P. (Fig. 679).— (1) Extension 
and moulding of the head and (2) engage- 
ment and descent are the same as in the 
anterior positions, except that they are 
apt to be tardy, as in posterior vertex 
positions (page 509, Fig. 681). (3) Ante- 
rior rotation of the chin from right to left 
about the right half of the pelvis to 
the symphysis is the normal mechanism. 
Should anterior rotation fail, we have re- 
sulting a persistent mento-posterior posi- 
tion (compare page 604) (Fig. 764). (4) 
Flexion and expulsion of the head are the 
same as in the anterior positions (Fig. 682). 
(5) In rotation of the trunk and restitu- 



FOURTH FACE POSITION. 
Left Mento-posterior, L. M. P. 




iAJ 



Fig. 683. — Face at Pelvic Inlet. 




Fig. 6S4. — Chin and Left Cheek in 
the Cervix. 




Fig. 6S5. — -Face at the Pelvic Floor 
before Anterior Chin Rotation. 




Fig. 686. — Restitution of the Head 
after Anterior Rotation of the 
Chin and Expulsion. 



566 



PATHOLOGICAL LABOR. 



MOULDING IN FACE PRESENTATION, 







\ 



Fig. 687. — Before Moulding. 




\ 



3 




Fig. 688. — After Mou 



■{Author's case.) 




Fig. 689. — Fetal Skull showing Moulding in 
Face Presentation. — {Author's collection.) 



tion of the head the right anterior 
or lower shoulder rotates to the 
symphysis. (6) Expulsion of the 
body follows. 

IV. Left Mento-posterior 
Position, L. M. P. (Fig. 683).— 
The cervico-bregmatic diameter en- 
ters the pelvis in the left oblique 
diameter, the chin pointing to the 
left sacro-iliac synchondrosis. (1) 
Extension and moulding of the 
head and (2) engagement and de- 
scent occur as in the R. M. P. posi- 
tion (Fig. 685). (3) Anterior rota- 
tion of the chin from left to right 
about the left half of the pelvis 
to the symphysis is the normal 
mechanism. Should anterior rota- 
tion fail, we have resulting a per- 
sistent mento-posterior position 
(compare page 604) (Fig. 764). (4) 
Flexion and expulsion of the head 
are the same as in anterior posi- 
tions (Fig. 682). (5) In rotation 
of the trunk and restitution of the 
head the left anterior or lower 
shoulder rotates to the symphysis 
(Fig. 683). (6) Expulsion of the 
body follows. 

Diagnosis. — The recognition of 
facial positions by external ex- 
amination has been pronounced 
impracticable by many diagnos- 
ticians. Ahlfeld, however, states 
that this type of faulty attitude 
may be recognized occasionally, 
while, according to Schatz, great 
pains and experience make such 
recognition practicable in routine 
diagnosis. Facial positions may 
be made out by external manipu- 
lation alone, before dilatation of 
the cervix, as follows: Pressure 
above the pelvic inlet reveals the 
presence of a prominent head 
(occiput). Having located the 
occiput in this manner, the small 
parts and fetal heart-sounds should 
be recognized on the opposite side 
of the uterus. The method re- 
commended by Schatz is as fol- 
lows : It depends for success upon 



FETAL DYSTOCIA FROM FAULTY ATTITUDE. 



567 



mapping out the convexity of the abdominal aspect of the fetus, and upon the 
demonstration that this convexity could not represent the normal dorsal arch 
of the vertex presentation (Fig. 692). If the fetus is in the cephalic position with 
breech in the fundus, the spinal convexity will be made more pronounced in a ver- 



m *m 




Fig. 



690. — Face Presentation. Originally in the right mento-posterior position, 
thor's case at the Emergency Hospital. — {From a photograph.) 



Au- 



tex presentation, by pressing upon the breech in the direction of the pelvic inlet, 
and the other hand will be able to trace the curvature from the breech down- 
ward. But in a facial presentation a convexity is also present, and an abdominal 
curvature which may simulate the dorsal arch. In palpating this convexity from 
the breech downward, the hand would locate the legs at the outset. Again, if the 



568 



PATHOLOGICAL LABOR. 



height of the convexity really represents the child's chest, pressure made by the 
hand upon the breech may be transmitted to the hand upon the chest. In facial 
presentation, in comparison with the normal vertex presentation, the fetus appears 
to have a short back, and limbs may be felt on both sides of the uterus, the 
legs above and at one side, the arms below and upon the other side. This 
peculiarity makes it expedient to exclude the probability of a twin pregnancy 




"Fig. 691. — -Face Presentation. Originally in the right mentoposterior position, 
thor's ease at the Emergency Hospital. — {From a photo graph.) 



Au- 



before making a diagnosis of a face presentation. In regard to internal recog- 
nition of face presentation, the usual method consists in mapping out the facial 
line, from the root of the nose to the chin. 

Prognosis. — In primiparous labors the prognosis for mother and child is 
considerably more unfavorable than in vertex cases. The prolongation of labor 
is an element which is naturally unfavorable to mother and child alike. The 






FETAL DYSTOCIA FROM FAULTY ATTITUDE. 



569 



mother's condition is also prejudiced by her great efforts to expel the child, 
while the special danger to the latter is found in the hyperextension of the head. 
The danger of birth trauma, with or without subsequent infection, is present here 
as in all labor in abnormal positions. In multi- 
parous labors the prognosis for mother and 
child is said to be little or not at all inferior to 
that of vertex presentations. The great im- 
provement in this respect in comparison with 
the fatality of the remote past is to be ascribed 
to the recognition of the fact that face presen- 
tation can take care of itself and that patience 
and expectancy are valuable traits in the ob- 
stetrician, if the labor is too far advanced to 
permit of correction of the faulty position. In 
21 face cases occurring in the Moscow Mater- 
nity Hospital during a period of ten years,* 17 
terminated without assistance, 2 by forceps, 
and 2 by craniotomy. All the mothers recov- 
ered. An element in the prognosis is found in 
the position of the chin, since a much higher 
mortality is found in posterior positions. In 
the latter the mother is exposed to the danger 
of severe laceration of the perineum, while the 
child has a relatively small prospect of sur- 
vival. The maternal mortality has been 
placed at 6 percent.; the fetal at 15 percent. 
The dangers for the mother are (1) those of 

protracted labor, or (2) of deformed pelvis, which latter so often complicates a 
face presentation. The dangers to the child are (1) those of prolonged labor; 
(2) cerebral congestion and apoplexy; (3) asphyxia from pressure on the vessels 
of the neck; (4) injury to the eyes during vaginal examination. 




Fig. 692. — Direction of Forces 
in the Conversion of a Face 
Presentation into a Vertex. — 
(Ahlfeld.) 



Position of Fetus. 



Left mento-ante- 
rior. L. M. A. 



Chin to left acetabulum, forehead to right 
sacro-iliac joint; back to right; extremities 
to left. 



Left mento-ante- Chin to right acetabulum, forehead to left 
rior. R. M. A. sacro-iliac joint; back to left; extremities 
to right. 

Right mento-pos- 
terior. R. M. P. 



Chin to right sacro-iliac joint, forehead to left 
acetabulum; back to left; extremities to 
right. 



Left mento-pos- ; Chin to left sacro-iliac joint, forehead to right 
terior. L. M. P. \ acetabulum; back to right; extremities to 
left. 



Fetal Heart-sounds. 



Left side of abdomen, 
below umbilicus. 



Right side of abdomen, 
below umbilicus. 



Right side of abdomen, 
below umbilicus. 



Left side of abdomen, 
below umbilicus. 



Treatment. — In this presentation more than in any other, successful treat- 
ment depends upon a thorough acquaintance with the mechanism of labor. The 
membranes should be preserved as long as possible, since the face is a poor 
dilator and the fore-water protects the face from injury. The friends should 
*SolowiefT: " Centralbl. f. Gynak.," Leipzig, 1898, No. 30. 



570 



PATHOLOGICAL LABOR. 



PRESENTATION OF THE ANTE 
RIOR PARIETAL BONE OR 
EAR; NAEGELE'S OB- 
LIQUITY. 



be informed that the face, when born, will be very much distorted. One 
should recollect that in a very large proportion of cases a face presentation 
does not require intervention until the face reaches the pelvic floor, and 

this holds good in both anterior and pos- 
terior positions of the chin. Fortunately, 
moreover, a persistent posterior position of 
the chin is of rare occurrence, not more than 
in one per cent, of all face positions, and 
in spite of the fact that the right mento- 
posterior position is second in frequency. 
In the absence of other factors of maternal 
or fetal dystocia expectancy is the key-note 
in the treatment. 

i. At the Pelvic Inlet. — In both anterior 
and posterior positions the case should be 
allowed to proceed without intervention, so 
long as labor progresses satisfactorily. The 
membranes must be preserved, however, 
and complete extension secured by upward 
pressure on the forehead. Some advise at 
this time attempts at conversion into a 
vertex presentation by the methods of 
Schatz and Baudelocque. The former is 
performed by external manipulations alone 
and can do no harm, but the manoeuver is 
too difficult of execution except in the 
hands of an expert. Should conversion be 
tried, conjoined manipulation will succeed 
best in the hands of the general practi- 
tioner. (See Operations, Part X.) Failure 
of engagement of the face at the inlet calls 
for conversion into a vertex, followed by 
high forceps or spontaneous labor in pos- 
terior chin positions, and podalic version 
and extraction in anterior chin positions, or 
conversion and high forceps in both. When 
delivery is impossible by these procedures, 
embryotomy is justifiable. 

2. In the Pelvic Cavity. — Delay in an- 
terior rotation of the chin often occurs for 
physical reasons, hence it must be favored 
by securing complete extension, by drawing 
forward the chin, by pushing back the fore- 
head, or by putting the ringers or a blade 
of the forceps under and behind the chin, 
to give the latter some hard substance to act upon. The indication arising, the 
forceps is to be applied. (See Operations, Part X.) For the treatment of per- 
sistent mento-posterior cases see page 605. 




Fig. '693. — At the Pelvic Inlet. 




Fig 



Fig. 695. — Anterior Parietal Bone 
and Ear in the Cervix. 



FETAL DYSTOCIA FROM FAULTY ATTITUDE. 



571 



V. PRESENTATION OF THE ANTERIOR PARIETAL BONE OR EAR. 
NAEGELE'S OBLIQUITY. (Fig. 693.) 



Normally the anterior parietal bone in 
lowest and most prominent in the cervix 
and vagina. When, however, excessive 
lateral flexion of the head occurs, to the 
extent, perhaps, of the presentation of 
the anterior ear, Naegele's obliquity of the 
head is said to be present. Naturally the 
sagittal suture approaches the sacral pro- 
montory and the posterior parietal bone is 
carried upward and backward. The latter 
is often found flattened after delivery and 
even depressed or fractured, and is over- 
lapped by the anterior. An exaggerated 
bregma presentation is usually present. 
The etiology of this complication is to be 
found in a pendulous abdomen, flattened or 
generally contracted pelvis, or other ob- 
struction permitting of the lateral flexion of 
the fetal head. The diagnosis is not dim- 
cult by ordinary vaginal palpation; but 
should doubt exist, the introduction of the 
whole hand into the vagina will remove any 
uncertainty. In left positions of the vertex 
the right parietal bone and perhaps the 
right ear will be found presenting; the 
small fontanelle high and to the left and 
the greater toward the right. Should the 
obstruction not be too great, the head may 
reach the pelvic floor in this way. The 
prognosis depends entirely upon the cause 
of the condition. In the lesser forms of 
pelvic contraction the prognosis is favor- 
able, also when the anomaly occurs as a 
transient condition, which it does in about 
one-third of all cases. The treatment con- 
sists in relief of the pendulous abdomen 
or anteverted uterus with an abdominal 
support or bandage in pregnancy (Fig. 
232), and the manual correction of the 
condition in labor if neessary. Nearly one- 
half of the cases rectify themselves spon- 
taneously. Of course, special treatment of 
the case is often demanded. 



vertex and bregma presentations is 



PRESENTATION OF THE POSTE- 
RIOR PARIETAL BONE OR EAR. 
LITZMANN'S OBLIQUITY. 




Fig. 697.— At the Pelvic Inlet. 




Fig. 698. — Posterior Parietal Bone 
and Ear in the Cervix. 



VI. PRESENTATION OF THE POSTERIOR PARIETAL BONE OR EAR. 
LITZMANN'S OBLIQUITY. (Fig. 696.) 

Here the sagittal suture approaches the symphysis, with the resulting pres- 
entation of the posterior parietal bone or ear. Incomplete flexion with the 



572 



PATHOLOGICAL LABOR. 



sinciput lower than the occiput will often be present. The condition usually 
occurs in markedly flattened pelves, the latter obstruction resulting in a lateral 
flexion of the fetal body and head, the reverse of the Naegele obliquity. Only 
rarely does Litzmann's obliquity occur in normal pelves. The highest degree 
of this, as of Naegele's obliquity, is the presentation of an ear. The diagnosis 
may cause some uncertainty unless the whole hand is introduced into the vagina, 
when the conditions above described will be readily recognized. The prognosis 
will usually depend on the amount and variety of the pelvic contraction; it is 

favorable in the so-called spontaneous cases 
and in moderate degrees of contraction. It is 
unfavorable in a moderate degree of general 
contraction should the brow enter the pelvis. 
The treatment in spontaneous cases consists 
in manual correction; and in pelvic contrac- 
tion, in appropriate treatment of the obstruc- 
tion. 



VII. PROLAPSE OF THE ARMS. DORSAL 
DISPLACEMENT OF THE ARM. 

In an obstetric sense prolapse of the arms 
is important only in connection with cephalic 
presentations, — vertex, brow, face, — as pro- 
lapse of the upper extremities in breech and 
shoulder presentations has little if any effect 
upon the course of labor, and is rather favor- 
able than otherwise. Presentation of a hand 
frequently occurs before rupture of the mem- 
branes, and after rupture either disappears by 
recession or the presentation is converted into 
a prolapse ; the arm then usually occupies the 
hollow of the sacrum and is often combined 
with prolapse of the cord. If the arm is far 
in advance, there is a chance of the head being 
deflected into the iliac fossa while the shoulder 
descends and a shoulder presentation occurs. 
If, however, the hand can just be palpated 
by the side of the head, it is likely that the 
latter will be born first while the hand stays 
behind. Also the hand when at the side of 
the pelvis — namely, at one end of the trans- 
verse diameter — is not so apt to be an impedi- 
ment as when it lies in front, for in this latter 
position it encroaches on the conjugate diam- 
eter. The position of the prolapsed hand is generally at one end of the bitem- 
poral diameter. Sometimes rotation is interfered with. If, however, the hand 
lies against the occiput, it may prevent its descent at least for a time, and 
cause head extension at the pelvic inlet (Figs. 701, 703, and 704). 

Etiology. — The causes are found in anything that disturbs the natural rela- 
tionship of the presenting part with the pelvic inlet. Thus malpresentations, 
such as shoulder, brow, face, are causes, since they do not properly engage at 
the inlet ; or anomalies in the shape of the uterus which have developed during 




OF 



Fig. 699. — Lateral Obliquity 
the Head in Vertex Presenta- 
tion. 



FETAL DYSTOCIA FROM FAULTY ATTITUDE. 573 

pregnancy from some cause or are due to tumor, hydramnios, or twins; or dis- 
placement due to pendulous abdomen. Pelvic contraction, as in the prolapse 
of the cord, is a common cause, as it prevents a proper adjustment of the present- 
ing part to the inlet. For the same reason multiple presentation, as in twins, and 
a premature fetus are causes. Rupture of the membranes in the sitting or stand- 
ing posture, especially in multiparae, and sudden exertion on the part of the 
mother during or even after engagement of the presenting part^ must be recog- 
nized as etiological factors. Death of the fetus with loss of its muscular tonicity 
must also be included 

Diagnosis. — This is a simple matter, and the possibility of this accident 
should always be one of the mental queries at all first and subsequent internal 
examinations of labor. 

Prognosis. — In shoulder and breech presentations prolapse of one or both 
arms is rather a favorable condition, and affects the prognosis accordingly. 
For this reason I am never accustomed to replace the prolapsed arm or arms 
under such circumstances. The advantage lies in the fact that we can usually 
apply a sling or soft fillet to the arm or arms, keep them prolapsed, and thus the 
subsequent danger of the arm or arms becoming extended and causing impaction 
of the after-coming head is obviated. Prolapse of an arm in vertex presentation 
is often a serious condition. The arm occupying the inlet with the vertex may 
result in a lateral deviation of the head, and a vertex presentation may thus be 
converted into a bregma, brow, or face, or, if the head is freely movable, even 
into a shoulder. Or, a less serious condition, an arm prolapsed behind the sym- 
physis may cause lateral flexion and presentation of the anterior parietal bone 
(Naegele's obliquity) or of the posterior (Litzmann's obliquity). The cause of 
the prolapse — whether it originates in the bony pelvis, the maternal soft parts, 
or the fetus — must not be lost sight of as affecting the prognosis. 

Treatment. — (i) In shoulder and breech presentations no treatment, in my 
opinion, is required, other than to secure the prolapsed arm or arms with a sling 
in order to prevent subsequent extension alongside or above the after-coming 
head. (2) In instances of prolapse of an arm or arms with the head when the 
latter is well engaged, an expectant treatment should be followed; and if delayed 
labor occurs, endangering fetus or mother, the forceps should be applied to the 
head, care being taken not to include the prolapsed arm, and the fetus extracted 
as in medium or low forceps operations. It will facilitate extraction if moderate 
traction is also made with a sling to the. prolapsed arm. Impaction in the case 
of a dead fetus of course demands perforation. (3) Manual reposition of the 
arm may be preceded, as a matter of duty, by an attempt at postural reposi- 
tion — namely, placing the patient in the exaggerated semi-prone, knee-chest 
or Trendelenburg posture. Postural reposition alone rarely succeeds. (4) 
When the head is movable at the inlet or is extra-medial by reason of the pro- 
lapsed arm filling in one side of the pelvis, and the arm thus constitutes an 
actual obstruction, manual reposition should be performed. This is the same 
as in the case of a prolapsed leg (see page 574). (5) Version and extraction 
may be required if reposition fails and indications of delayed labor demand 
intervention. 

Dorsal Displacement of the Arm (Figs. 700, 702). — In cephalic and breech 
presentations it occasionally happens that an arm is not only prolapsed, but is so 
displaced that the forearm lies transversely across the back of the neck behind 
the occiput and forms a ridge or elevation in the generally uniform fetal ellipse 
which may catch upon the pelvic inlet or a rigid cervix and constitute a serious 
obstruction to labor. Diagnosis : The condition is the more dangerous because, 



574 PATHOLOGICAL LABOR. 

as no appreciable change occurs in the presentation, it naturally escapes diagnosis 
unless the hand of the attendant is passed above the head to explore for the cause 
of delay. Such an exploration under ether is always called for when forceps- 
indication with no marked disproportion between the head and fetus is evident 
and traction fails to bring down the head. Treatment : ( i ) In Cephalic Presen- 
tation. — In spite of the obstruction the fetus can sometimes (a) be delivered by 
moderate traction with the forceps. Strong traction must not be employed for 
fear of injury to the fetal neck. (6) The forceps failing, an attempt should be 
made with the hand passed between the shoulder and the pelvic wall to flex the 
forearm back into its proper place over the scapula, and the lateral and anterior 
thoracic walls. Fracture of the arm is occasionally unavoidable, (c) The forceps 
and manual rectification having failed, combined or internal podalic version under 
proper conditions of fetus and uterus must be performed. (2) In Breech Pres- 
entation and Breech Extraction. — Delay here from dorsal displacement of 
the arm is more important than in cephalic presentation, since shorter time is 
allowed for removing the obstruction and fetal asphyxia in the mean time is liable 
to occur, (a) A conservative as well as effective plan of procedure is to bring 
down the non-displaced arm, to put a sling upon it, and, by using this arm as a 
tractor as well as by grasping the trunk, to rotate the latter in the direction that 
will disengage the displaced arm. (b) The replacement thus accomplished will 
usually be only partial, and it will be necessary, after rotating the displaced 
arm into the posterior part of the pelvis, to pass the whole or half hand into the 
pelvis and sweep the now partially displaced arm over the face and chest. It 
may possibly be necessary deliberately to fracture the arm in order to liberate the 
fetus in time to prevent its death by asphyxia. (Compare Part X.) 

VIII. PROLAPSE OF THE LEGS. 

Prolapse of the lower extremities is unusual in any presentation. It is rather 
favorable than otherwise in breech and shoulder presentations, and occurs, as a 
rule, only when the fetus is dead, immature, or macerated. In certain breech 
presentations there is extension of one or both thighs from vigorous movements 
on the part of the fetus or from sudden outflow of liquor amnii. Thus one or 
both feet or one or both knees or a knee and a foot present. An influencing 
factor in this condition is the fact that the breech does not fully occupy the 
lower uterine segment, especially when there is much liquor amnii. Frequency : 
Footling presentations are said to occur once in 92 cases, or in a little over 1 per 
cent, of all breech cases. Knee presentations are very rare, occurring once in 
3000 cases. The simultaneous presentation of hand and foot is extremely rare. 
Treatment: (1) In shoulder and breech presentations no treatment is required 
other than to secure the prolapsed leg with a sling. In the rare instances in 
which prolapse of the leg occurs with cephalic presentation (vertex, brow, or 
face) the treatment will vary according to circumstances (Figs. 704, 705). 
(See Part X.) 

IX. PROLAPSE OF THE UMBILICAL CORD. 

Synonyms: Prolapsus Funis; Chorda Praevia; Funicular Presentation. 

Definition. — In this instance a loop of the umbilical cord descends into the 
pelvis in advance of the presenting part. If the membranes remain unruptured, 
the condition is known as presentation of the cord, but after rupture, when the 
cord descends into the vagina, it is called prolapse of the cord. Before rupture, 




575 



576 



PATHOLOGICAL LABOR. 



the loop of cord may be felt through the membranes moving in the liquor amnii, 
and from the very beginning of labor it presents at the pelvic inlet. It may be 
carried down by the sudden outflow of liquor amnii when the membranes rupture, 
or the loop may be forced down by muscular action by the side of the engaged 
head, and thus escape from the vulva. Sometimes both arms of the loop are 
seen side by side; in other cases the two parts are separated by a fetal part. 
The most common position in which the loop is found is in front of one of the 
sacro-iliac joints or of the cotyloid cavity. It is seldom directly in front of the 
sacrum or behind the pubic arch. The last-named positions are most dangerous, 
as they give most chance for compression of the cord by the fetal parts (Figs. 
708 and 709). 

Frequency. — The frequency of this complication varies, in different countries 
and in different institutions, with the frequency of pelvic deformity and the 

posture of the parturient woman during 
labor. On the whole, it is not very infre- 
quent. One estimate gives it as occurring 
once in from 200 to 300 cases of labor, but 
the limits according to various authors, 
range between one in 65 and one in 500 
cases. In 2200 confinements in New York 
city I found the cord was prolapsed in 26 
cases, or in 1.18 per cent., or once in 84.6 
cases. 

Etiology. — The cause of this condition 
is found in a lack of accommodation be- 
tween the presenting part and the lower 
uterine segment and the pelvic inlet. Mal- 
presentations, malpositions, deformities of 
the head, and contractions of the pelvis act 
as predisposing causes. In 26 cases of pro- 
lapse of the cord I found 14 vertex presen- 
tations, 1 brow, 3 shoulder, and 8 breech, 
one of the last being a prolapsed foot as 
well. In 9 of the 26 cases some form of 
pelvic contraction was present. Eight of 
the cases were in primiparas and 18 in 
multiparas. Excessive right lateral ob- 
liquity of the uterus, uterine fibromata or myomata, hydramnios, too long 
cord, marginal insertion of the cord, placenta prasvia, plural pregnancy, 
multiparity, pendulous abdomen, a male fetus, complex presentation, or the 
presence of a very small fetus in premature labor, predispose to prolapse of the 
cord. Cases have been reported in which this complication has occurred in 
successive pregnancies, and in the absence of an obvious cause, predisposition 
has been said to be the etiological factor. The upright position on the part of 
the mother at the time of rupture of the membranes, and a sudden escape of the 
liquor amnii, may act as exciting causes, as may also violent movements, or 
efforts at bearing-down, particularly if ergot has been used prematurely in the 
last instance. 

Diagnosis. — The diagnosis differs somewhat whether made before or after the 
rupture of the membranes. It should be simple enough after the rupture of the 
membranes, especially if the loop of cord has fallen into the vagina or outside 
the vulva. It may be distinguished from a prolapsed intestine by the absence 




Fig 



708. — Prolapse of the Cord in 
Vertex Presentation. 



FETAL DYSTOCIA FROM FAULTY ATTITUDE. 



oil 



of a mesentery, and by the characteristic twists of the umbilical cord which can be 
felt, and, if the child still lives, by the presence of pulsation in the cord. In 
some cases, however, pulsation in the cord ceases a short time before the death 
of the child, so that the heart should be auscultated before death is decided to 
have occurred. If the membranes are still unruptured and the pulsation is ab- 
sent, the diagnosis is not quite so clear. ■ Pulsations which occur in the vaginal 
or uterine arteries may be distinguished from those of the cord by being syn- 
chronous with the pulse of the mother. Before the escape of the liquor amnii, 
the cord, being non-resisting, is pushed ahead of the examining finger until it is 
really beyond palpation. Prolapsed cord has also to be differentiated from the 
presence of a foot or a- hand in the vagina, an ectopia of the fetal intestines, and 
cedematous and lacerated lip of the cervix. 

Prognosis. — The mortality among children in this condition amounts to 50 
per cent. The prognosis for the child depends on the time of labor at which the 
prolapse occurs, the presentation and position of the fetus, the condition of the 
membranes, the condition of the cervix, the amount of cord prolapsed, and the 
gravity of the abnormality causing the 
accident . The great danger for the child 
is from asphyxia due to compression of 
the cord. Head presentation carries the 
greatest danger with it. The danger is 
less in proportion to the greater length of 
time that the membranes remain intact, 
and, after their rupture, in proportion to 
the rapidity of delivery. The amount of 
the cord prolapsed and the region of the 
pelvis into which it descends also in- 
fluence the prognosis. The fetal mor- 
tality is higher in primiparas and in 
oversize of the fetus. 

The prognosis for the mother depends 
upon the gravity of the abnormality 
which causes the accident, and of the 
operation demanded. Mental disturb- 
ance and breast complications subse- 
quent to the death of the fetus may have 
some effect on the mother. Cases do 
occur in which, from various causes, the cord is tightly stretched, and is thus so 
shortened that the placenta is prematurely detached, with resulting hemorrhage. 
In my 26 collected cases, one mother died on the fifth day, undoubtedly as the 
result of the operation to save the child, and 5 of the 26 children were still-born. 

Treatment. — The treatment of this condition is most important because of 
the high mortality among children. Whatever measures are instituted should 
be promptly applied. 

1. Preventive Treatment consists in posture of the parturient, preserva- 
tion of the membranes, and immediate correction of lateral displacement of the 
presenting part. Many cases are due to improper management of labor. The 
membranes should never be ruptured prematurely without a positive indica- 
tion, and the waters should never be allowed to gush from the uterus when 
the woman is in the erect or sitting posture. In excess of the liquor amnii, 
a gradual escape of the waters should be aimed at by partially occluding the 
vaginal outlet with gauze or cotton. In conditions favoring prolapse the 
37 




Fig. 709. — -Prolapse of the Cord in a 
Doubled Fetus, the Anterior Fetal 
Plane Presenting. 



578 PATHOLOGICAL LABOR. 

woman should be kept in the dorsal posture during the first as well as the 
second stage. 

2. Curative Treatment. — If the child is dead, the presentation or prolapse 
of the cord does not, of course, constitute a special indication, for the interests 
of the mother do not require that the fetus shall be extracted at once. 

In the curative treatment of presentation of the funis before dilatation of the 
cervix has taken place, or rupture of the membranes, active interference is not in- 
dicated. Every effort should be made to prevent the premature rupture of the 
membranes. For this purpose a Barnes bag may be introduced, or the vagina may 
be tamponed. The patient should be cautioned against straining, and should 
assume the exaggerated latero-prone position (Part X) on the side opposite to that 
on which the cord lies, in order that gravity may favor the return of the displaced 
cord. The knee-chest position is also frequently useful in causing the return of 
the cord. If the fetal heart-sounds begin to fail, the cord should be pushed up be- 
tween the pains, care being taken not to rupture the membranes. This should be 
done while the. patient is in the knee-chest position. If the cord does not return, 
the membranes should be ruptured, and sufficient descent of the head secured to 
retain the cord, by expression of the fetus or by using forceps. After the cord 
has been replaced, the patient should lie upon the side, as above described, and 
with the hips elevated by a pillow. If the accoucheur possesses the requisite 
experience and skill, and if the mother's condition permits, he may perform 
version by the combined method, but without bringing down the foot into the 
vagina. The foot should be secured by a fillet. 

In the treatment of presentation of the funis after dilatation of the cervix, if 
the head remains above the brim and cannot be made to engage, there are 
two alternatives: manual or instrumental reposition and version. Too much 
handling of the cord, however, is dangerous to the fetus. If reasonable efforts 
at reposition fail, version should be performed, unless it is so dangerous to the 
mother as to be considered unjustifiable. 

Manual reposition is best done while the patient is in the exaggerated latero- 
prone or knee-chest position. While counter-pressure is made over the fundus, 
the hand should be passed into the cervix, the head pushed a little to one side, 
and the cord carried up beyond the head, and, if possible, to a position behind the 
neck. During this manipulation the cord should be balanced on the tips of as 
many fingers as possible and not grasped in the hollow of the hand. This act 
of reposition should be done as rapidly as possible Manipulations should be 
suspended during uterine contractions. The hand should be gradually with- 
drawn, and the descent of the head into the cervical canal aided by pressure 
over the fundus, or the application of the forceps. After reposition the 
woman should be placed on the side opposite to that at which the prolapse 
developed. 

Instrumental reposition will become necessary if rupture of the membranes 
takes place before dilatation of the cervix, since the time occupied in securing 
dilatation would very likely prove fatal to the child. The best repositor is an 
ordinary English catheter (See Part X). The stylet is made to pass out from the 
eye of the catheter, a loop of disinfected bobbin is passed loosely around the 
cord, and is attached to the stylet, which is then withdrawn into the catheter 
and pushed to the tip, in order to hold the tape in position. The catheter and 
cord are then carried up as far as possible, the stylet is withdrawn to avoid 
possible compression, and the catheter is left in position. Every effort should 
then be made to induce engagement as described above. If efforts at reposition 
are not promptly successful, manual dilatation, followed by version or forceps, 



FETAL DYSTOCIA FROM FAULTY PRESENTATION. 579 

according to the indications, should be performed. Another method of slinging 
the cord is shown in Part X. 

In face presentations version should be performed, unless there are contra- 
indications, since the face -does not completely fill the cervical canal, and the 
replaced loop is likely to re-prolapse. In prolapse of the foot in breech pres- 
entations the cord is not in danger until the breech enters the cervix. In 
breech presentations pressure upon the cord may be relieved by bringing down 
a foot, but if the fetal heart-sounds begin to fail, extraction should be as rapid 
as is consistent with the safety of the mother. In shoulder presentations no 
modification of the usual management is indicated. In the very rare cases in 
which the head is impacted, or has passed the inlet, and the cord pulsates, the 
use of the forceps is indicated. After the child is dead the condition does not 
call for interference. If there are still other complications, such as placenta 
previa or shoulder presentation, the same treatment is indicated as at first 
described. When prolapsed cord offers the only complication, it should be 
restored as quickly as possible. Throughout the management of the case the 
operator or an assistant should listen at intervals for the fetal heart. If 
asphyxia appears to be impending before dilatation of the cervix is com- 
plete, the Braxton-Hicks method of version may be performed, although the 
foot should not be brought below the level of the os, where it may be held 
by a sling until dilatation is complete. If fetal asphyxia is impending after 
dilatation is complete, podalic version should be performed if the head is 
movable at the inlet; otherwise forceps must be applied. In my series of 26 
cases, above quoted, with a fetal mortality of 19.2 per cent., 8 children were 
delivered by forceps, 9 by version, 4 by manual extraction in breech cases, and 
3 spontaneously. Records are wanting in 2 cases. 



FETAL DYSTOCIA FROM FAULTY PRESENTATION. 

. X. PELVIC PRESENTATION. 

Definition. — Pelvic or breech presentation represents positions of the fetus 
in which the inferior pole of the fetal ellipse is found at the pelvic inlet, in the 
vagina, or at the vulva. It is classed as a longitudinal presentation, and therefore 
is amenable to the conditions of that class. The positions are named in accord- 
ance with the location of the fetal sacrum (page 581). It is unnecessarily com- 
plicating to describe in this connection a foot and knee presentation. Prolapse 
of the feet and legs is merely a complication of a pelvic presentation as prolapse 
of the cord and hands is in other presentations — vertex, bregma, brow, face, 
or shoulders. It is useful, however, to distinguish between a simple pelvic pres- 
entation and a mixed one. In a simple breech presentation the lower extrem- 
ities are flexed on the anterior surface of the body. Flexion is limited to the 
hip-joint, the knee being in extension. The breech alone presents at the inlet 
(Figs. 711, 712). In a mixed breech presentation the lower extremities maintain 
the physiological attitude throughout, hips, knees, and ankles alike exhibiting 
some degree of flexion ; so that the feet are found in some relationship with the 
breech at the pelvic inlet — perhaps above, perhaps below (Fig. 715). 

Frequency. — Statistics covering a vast number of child-births show that about 
one labor in thirty-two is a breech presentation, the percentage being 3.2. A 
large proportion of breech cases is found in premature deliveries, multiple preg- 



580 



PATHOLOGICAL LABOR. 



nancies, and anomalous labors (page 473)- Simple breech occurs in about 60 per 
cent, of cases. In 2200 labors I found pelvic presentation occurred in 82 cases, 

or 3.72 per cent., or once in 

.-- -.. 26 labors. 

Etiology. — The etiology of 
breech cases is complex, so 
that the theoretical causal 
factors cannot always be 
brought into relationship with 
this anomalous presentation. 
In general it may be stated 
that anything which inter- 
feres with the normal shape 
of the fetal ellipse or changes 
the shape of the ovoid uterine 
cavity after the thirty-second 
week may result in a malpres- 
entation, such as pelvic; in 
other words, there is failure of 
one or more factors governing 
the determination of vertex 
presentation (compare page 
474). Certain conditions pre- 
dispose to breech presenta- 
tions: (1) First, the causes of 
faulty attitude in general, in- 
cluding pelvic, shoulder, and 
possibly face presentation. 
These include, on the part of 

,, -d -n r, the mother, relaxation of the 

-Mixed Breech Presentation. Compare . ' . 

Fig. 715. uterine and abdominal walls, 




Fig. 710.- 





Fig. 711. — Simple Breech Presen- 
tation. 



Fig. 712. — Simple Breech Presentation. 



FETAL DYSTOCIA FROM FAULTY PRESENTATION. 581 



abnormal mobility of the uterus (conditions found in women who have borne 
many children); distention of the uterus (hydramnios) , deformity of the uterus, 
whether due to malformation (uterus arcuatus, bicornis, etc.) or to fibroids; con- 
tracted pelvis; placenta prasvia. (2) On the part of the fetus the corresponding 
factors are prematurity (we must expect breech presentation in every second 
case of labor before the eighth month, page 473) ; multiple pregnancy; monstrosi- 
ties; fetal diseases, dead and macerated fetuses. We frequently see the coinci- 
dence of several of these factors in a given case. 
Positions and Relative Frequency. — 
I. Left sacro-anterior, Sacro lasva anterior, L. S. A. (Fig. 714), most frequent. 
II. Right sacro-anterior, Sacro dextra anterior, R. S. A. (Fig. 723). 

III. Right sacro-posterior, Sacro dextra posterior, R. S. P. (Fig. 727), second 

in frequency. 

IV. Left sacro-posterior, Sacro laeva posterior, L. S. P. (Fig. 731). 

The left sacro-anterior is the most frequent, and the right sacro-posterior the 
next. In 163 pelvic presen- 
tations, Naegele found 120 
left sacro-anterior and 40 
right sacro-posterior. The 
same factors determine the 
relative frequency of the 
several breech positions as 
those of the vertex (page 
477). To understand this 
one must keep in mind the 
shape of the fetal ellipse; 
the shape of the uterine 
cavity; the torsion of the 
uterus upon its long axis, 
and the fact that in pelvic 
as in vertex presentation 
the longest horizontal diam- 
eter of the fetal ellipse is 
an antero-posterior and not 
a transverse diameter (Figs. 
710, 712). This is brought 
about by the flexion of the 

thighs, legs, arms, and head upon the anterior fetal plane in the normal 
attitude or posture (page 470). 

Mechanism. — I. Left Sacro-anterior, L. S. A. (Fig. 714). — The same stages 
obtain here as in the mechanism of vertex presentation. The bitrochanteric 
diameter (Fig. 715) approaches the pelvic inlet in the latter's left oblique diam- 
eter, the fetal back looking to the left and front (Fig. 714). (1) Moulding 
of the breech: Increased intrauterine pressure results, in addition to moulding, 
in more perfect flexion of the limbs and head. No movement analogous to 
flexion in vertex or extension in face presentation occurs, nor does a typical 
tumor like the caput succedaneum form. This process is also one of adaptation. 
The breech is swollen either from simple oedema or the condition may be more 
severe and present a much enlarged, dark surface. It is more commonly seen 
over the anterior hip, though it may reach the genital regions, especially the 
scrotum in males. If the knees or feet present, they may have the same appear- 
ance. (2) Engagement and descent:'By reason of the irregular shape of the breech 




Fig. 



98-99^ 



713. — Relative Frequency 
Positions. 



of the Breech 



582 



PATHOLOGICAL LABOR. 



FIRST BREECH POSITION. 
Left Sacroanterior, L. S. A. 



&X 




Fig. 714. — Breech at the Pelvic 
Inlet. 




•.-..,. 



Fig. 715. — Breech at the Pelvic 
Inlet. 




Fig. 716. — Left Buttock in the 
Cervix. 




Fig. 717. — Left Buttock in the 
Vulva. — (From a photograph.) 



this stage is often prolonged. The left an- 
terior or lower hip first enters the inlet and 
cervix (Figs. 715 and 716) and slowly the 
uterus forces the breech onward into the 
pelvic cavity until the left hip meets with 
the resistance of the pelvic floor. (3) An- 
terior rotation of the left hip: Rotation of 
the buttocks occurs when the pelvic floor 
is reached. It must be clearly understood 
that while the greatest horizontal diameter 
of the fetal ellipse is the antero-posterior, 
yet the greatest diameter of the presenting 
part or breech is the transverse diameter, 
the bitrochanteric, 3^ inches (8.75 cm.) 
(Fig. 712). One must also remember that 
in the stage of descent that buttock or 
trochanter which lies in the anterior seg- 
ment of the pelvis is the lowest, and hence 
the first to be influenced by the trough- 
like shape of the pelvic floor and deflected 
to the front at the pelvic outlet, thus 
bringing the long diameter of the present- 
ing part (bitrochanteric) into the long 
diameter of the pelvic outlet (antero-pos- 
terior), and fulfilling the great principle 
in the mechanism of labor, namely, accom- 
modation (Figs. 716,717). The left, lower, 
or anterior buttock is thus brought to the 
symphysis pubis by the rotation of the 
breech in its entirety. (4) Expulsion of 
the breech and lateral flexion of the body: 
When the anterior hip has reached the 
pubis, and the posterior the posterior por- 
tion of the pelvic floor, the impetus given 
the fetus by the posterior segment bends 
forward the breech in its entirety and a 
lateral curvature of the trunk occurs 
(Fig. 136). The lateral curvature soon 
becomes decided and the buttock may be 
seen at the vulval opening. The trunk 
is propelled into the pelvic cavity and the 
anterior hip becomes fixed beneath the 
pubic arch. Next the posterior hip makes 
onward progress until the posterior buttock 
appears over the fourchette, followed by 
the trochanter. With the birth of the pos- 
terior part of the breech the perineum with- 
draws from the pelvis of the fetus, and on 
account of the posterior surface of the 
breech being relieved entirely of pressure 
there is decreased curvature and the fetal 
trunk straightens out, freeing the anterior 



FETAL DYSTOCIA FROM FAULTY PRESENTATION. 



583 



hip from its forced position against 
the arch of the pubis ( Fig. 726). Ex- 
pulsion of the trunk now readily fol- 
lows. The thighs are always flexed 
when no prolapse occurs and the legs 
are often extended (Fig. 711). Ex- 
tension of the legs I do not consider 
an abnormal condition, as it is due 
to the tight birth canal "peeling" 
them up, so to speak, along the fetal 
body. Normally the arms preserve 
their original position upon the chest 
of the fetus and are thus expelled. 
An unfortunate complication arises 
should one or both arms become ex- 
tended along the sides of the head 
within the pelvis. The hips, the legs, 
and the trunk appear in quick suc- 
cession, and the child is delivered up 
to its waist. Almost simultaneously 
the shoulders enter the inlet and the 
umbilicus appears at the vulva. The 
bisacromial diameter of the shoulder 
engages in the left oblique diameter of 
the pelvic inlet and the shoulders de- 
scend until the left, lower, or anterior 
shoulder reaches the pelvic floor. 
The left shoulder then rotates an- 
teriorly from right to left, causing the 
bisacromial diameter to correspond to 
the antero-posterior diameter of the 
pelvic outlet. The anterior shoulder 
becomes fixed under the pubic arch. 
The arms, flexed on the chest, and 
the shoulders, first the right or pos- 




Fig. 718- 
Head 



-Delivery of the After-coming 
with the Occiput Anterior. 




Fig. 719.- 
Head 



-Delivery of the After-coming 
with the Occiput Anterior. 




Fig. 720. — Delivery of the After-coming 
Head with the Occiput Anterior. 




Fig. 721. — Delivery of the After-com- 
ixg Head with the Occiput Poste- 
rior. First Method. 



Fig. 722. — Delivery of the After-com- 
ing Head with the Occiput Posterior. 
Second Method. 



584 



PATHOLOGICAL LABOR. 



SECOND BREECH POSITION. 
Right Sacroanterior, R. s. a. 



■*> 




T 



Fig. 723. — Breech at Pelvic Inlet. 




Fig. 724. — Breech at Pelvic Inlet. 




Fig. 725. — Right Buttock in the 
Cervix. 




Fig. 726. — Breech in the Vulva. 
Expulsion of both Buttocks. 



terior, and later the left or anterior, are 
delivered. (5) Rotation of the head and 
restitution of the trunk: The head, regarded 
as a lever, is pressed upon at its longer 
arm by the uterus, and this serves to keep 
it flexed or to increase existing flexion. 
The head engages and descends. The 
occipito-frontal diameter of the head enters 
the pelvis in its right oblique diameter. 
In perfect flexion of the head and normal 
posture of the child the vertex or occiput 
is the only prominent or projecting por- 
tion. Consequently at the pelvic floor it 
is this pole of the head which alone meets 
with any resistance and, following the 
usual law, is deflected anteriorly, bringing 
the long diameter of the head into that 
of the outlet. Anterior rotation of the 
occiput we know clinically rarely fails, 
and then because of an extended head or 
some anomaly either in the shape of the 
head or parturient tract. Coincident with 
head rotation, slight restitution of the 
trunk, bringing the fetal dorsum to the 
front, is sometimes observed. (6) Expul- 
sion of the head: Although acting at a dis- 
advantage by reason of the relatively small 
size of the head, the uterus by contracting 
acts upon the vault of the cranium. The 
occiput still being the projecting and 
prominent portion of the head, and in the 
anterior segment of the pelvic outlet, is 
naturally caught and held by the bony 
fork of the pubic arch, leaving the long 
or sinciput extremity of the cephalic lever 
to be influenced by the contraction of the 
uterus and pelvic floor and to be driven 
down into the vulval opening, causing the 
head to be born by a movement of flexion ; 
the chin, mouth, nose, eyes, forehead, 
anterior fontanelle, and lastly the occiput 
passing over the perineum in the order 
named (Figs. 718, 719, 720). 

Posterior Rotation of the Occiput. — In 
rare cases, not more than 2 per cent., 
anterior rotation of the occiput fails, the 
sinciput end of the cephalic lever rotates 
to the pubic arch and the occiput to the 
coccyx. This complication results from 
incomplete flexion of the head, whereby 
the sinciput of the after-coming head 
becomes as prominent as the occiput or 



FETAL DYSTOCIA FROM FAULTY PRESENTATION. 



585 



more so, and hence is equally or to a 
great extent influenced by the greater 
resistance of the posterior part of the 
pelvic floor, and is rotated anteriorly. 
Two terminations of a persistent occipito- 
posterior position of the after-coming head 
are possible: (i) Uterine contractions force 
the sinciput, or long end of the head lever, 
under the pubic arch and flex the head 
through the vulval orifice; the chin, 
mouth, nose, eyes, forehead, and occiput 
appearing in the order named under the 
pubis (Fig. 721). (2) Occasionally exten- 
sion of the head takes place at the pelvic 
inlet and the occipito-mental diameter 
(5^ inches — 13.97 cm.) is brought in co- 
incidence with the antero-posterior diam- 
eter of the inlet, thus presenting a me- 
chanical impossibility. In these cases 
contraction of the uterus forces the chin 
over and upon the upper portion of the 
symphysis and thus fixes the face end of 
the cephalic lever. The occipital or short 
end of the head lever alone being free, is 
forced by uterine contraction down to the 
pelvic floor and the head is born through 
the vulval orifice by a movement of con- 
tinued extension; the occipital protuber- 
ance, the small and large fontanelles, fore- 
head, nose, mouth, and lastly the chin 
being born in the order named (Fig. 

723). 

II. Right Sacro-anterior Position, 
R. S. A. (Fig. 724). — The bitrochanteric 
diameter approaches the pelvic inlet in 
the latter' s right oblique diameter, the 
fetal back looking to the right and front. 
(1) Moulding of the breech: Same as in 
Position I (page 581). (2) Engagement 
and descent: Same as in Position I (page 
581). (3) Anterior rotation of the right 
hip: This occurs for the same reason as in 
Position I (page 582). (4) Expulsion of 
the breech and lateral flexion of the body: 
Compare Position I (page 582). (5) Rota- 
tion of the head and restitution of the trunk: 
The occipito-frontal diameter enters the 
left oblique pelvic diameter and the occi- 
put rotates to the pubis from right to left 
(Fig. 723). Restitution occurs as in Posi- 
tion I. (6) Expulsion of the head (Fig. 
718): See Position I (page 583). 



THIRD BREECH POSITION. 
Right Sacroposterior, R. S. P. 




Fig. 727. — Breech at Pelvic Inlet 




Fig. 7 28. — Breech at Pelvic Inlet 




Fig. 729. — Right Buttock in the 
Cervix. 




Fig. 730. — In the Vulva. Escape 
of the Anterior or Right Leg. 



586 



PATHOLOGICAL LABOR. 



FOURTH BREECH POSITION. 

Left Sacroposterior, l. s. p. 



III. Right Sacroposterior Position, R. S. P. (Fig. 727). — The bitro- 
chanteric fetal diameter approaches the left oblique pelvic diameter; the fetal 
back looks to the right and rear (Fig. 728). (1) Moulding of the breech and (2) 
Engagement and descent occur as in Positions I and II. (3) Anterior rotation 
of the right hip now occurs (Fig. 729). (4) Expulsion of the breech and lateral 
flexion of the body follow (see pages 582 and 583) (Fig. 730). (5) Rotation of 
the head and restitution of the trunk: The occipitofrontal fetal diameter enters 
the right oblique pelvic diameter, the occiput pointing to the right sacro-iliac 
synchondrosis. Rotation of the occiput follows from this latter point around 
the right pelvic wall and to the symphysis, for reasons already stated, in all but 
less than 2 per cent, of cases (Fig. 727). (6) Expulsion of the head now occurs 
as in Positions I and II (Fig. 718). 

IV. Left Sacro-posterior Position, L. P. S. (Fig. 731). — The bitrochan- 

teric fetal diameter approaches the left ob- 
lique pelvic inlet diameter; the fetal back 
looks to the left and rear (Fig. 732). (1) 
Moulding of the breech and (2) Engagement 
and descent occur as in Positions I and II 
(Fig. 733). (3) Anterior rotation of the left 
hip: This occurs from left to right to the 
median line (Fig. 733). (4) Expulsion of 
the breech and lateral flexion of the body: 
As in I, II, and III (Fig. 718). (5) Rota- 
tion of the head and restitution of the 
trunk: The occipito-frontal fetal diameter 
enters the left oblique pelvic diameter, the 
occiput pointing to the left sacro-iliac 
synchondrosis. Rotation of the occiput 
around the left side of the pelvis to 
the symphysis occurs at the floor of 
the pelvis (Fig. 731). (6) Expulsion of 
the head follows (Fig. 718). 



Fig. 731. — Breech at Pelvic Inlet. 





Fig. 732. — Breech at Pelvic Inlet. 





Fig. 733. — Left Buttock in Cervix. 



Fig. 734. 



-Escape of the Trunk through 
the Vulva. 



FETAL DYSTOCIA FROM FAULTY PRESENTATION. 



587 



Prognosis. — For the mother: The prognosis in respect to the mother's survival 
corresponds to that of occipital presentations in all cases which terminate 
spontaneously, although intervention is required much more frequently in 
breech cases. The likelihood of perineal rupture is also greater. For the child: 
The prognosis for the fetus is much more unfavorable than in occipital presenta- 
tions; the average mortality being 20 per cent. The chief danger is from 
asphyxia, which often occurs as the after-coming head passes the pelvic inlet 
coincident with the birth of the navel. An additional peril is compres- 
sion of the cord between the fetal parts and the pelvic bones. Complete com- 
pression for five to ten minutes is sufficient to kill a strong, healthy child. Third, 
premature detachment of the placenta may cause death of the child. Partial 
detachment often results irrespective of the fetal position when the uterus is 
partially emptied ; but while this has no special significance in head presentations 
it is otherwise when the head is still in the uterus and respiration impossible. 
Under these circumstances the prognosis is not necessarily ominous because it 
may be improved by treatment. In regard to the prognosis of particular types 
of pelvic presentations, the best outlook occurs in mixed breech cases, because the 
entire circumference of the trunk and lower extremities serves to dilate the birth 
tract. Conversely, if the feet constitute the presenting part, the prognosis is unfa- 
vorable because a complete foot presentation cannot dilate the birth tract suffi- 
ciently for delivery of the after-coming head. The first risk of the child, death from 
asphyxia, irrespective of compression of the cord or detachment of the placenta, 
is due to premature inspiration, produced by the contact of the born portions of 
the body with the cooler outside air. Respiration causes aspiration of mucus with 
obstruction of air-passages. Extension of one or both arms is an unfortunate 
complication, which still further prolongs the expulsion of the head. Because the 
uterus cannot grasp the breech so firmly as it can the head, and thus while the 
fore-waters still have communication with the rest of the liquor amnii, there is 
premature rupture of the membranes from this unusual force of uterine con- 
tractions. Dry labor may ensue. Fractures and dislocations often occur when 
interference is necessary. Hematoma of the sterno-mastoid and torticollis have 
also been noted in connection with breech delivery. 

Diagnosis. — 



Position of Fetus. 



Position of Fetal Heart- 
sounds. 



Left sacro-ante- Sacrum to left acetabulum; back to left ante- 
rior. L. S. A. rior; abdomen to right posterior. 

Right sacro-ante- Sacrum to right acetabulum; back to right 
rior. R. S. A. t anterior; abdomen to left posterior. 

Right sacro-pos- Sacrum to right sacro-iliac joint; back to 
terior. R. S. P. , right posterior; abdomen to left anterior. 

Left sacro-poste- \ Sacrum to left sacro-iliac joint; back to left 
rior. L. S. P. posterior; abdomen to right anterior. 



Left side of abdomen, 
opposite umbilicus. 

Right side of abdomen, 
opposite umbilicus. 

Right side of abdomen, 
opposite umbilicus 
and toward the back. 

Left side of abdomen, 
opposite umbilicus 
and toward the back. 



External Examination. — If the fundus uteri is palpated the head may be 
recognized in that locality in the first position on the right side and in the second 
position to the left (Figs. 714 and 723). The back is recognized by its uniform 
resistance. On the opposite side of the uterus, occupied chiefly by liquor 
amnii, the resistance is much less marked. In palpating over the pelvic inlet we 
encounter not the head but a less resistant structure. The lower extremities 



588 



PATHOLOGICAL LABOR. 



HEAD MOULDING IN BREECH PRESEN- 
TATION. 






7 




* 






Fig. 735. — Before Moulding. 



T' 



Fig. 736. — After Moulding. — (Author's case.) 




may be made out in the inferior 
uterine segment. The fetal heart 
should be heard, in the first posi- 
tion, just to the left of the median 
line and at the height of or a little 
above the umbilicus. In the second 
position the heart should be heard 
on the right side at some distance 
from the median line and some- 
what further back, the level being 
the same as in the first position. 

Internal Examination. — As a 
rule, the breech is higher up at the 
beginning of labor than is the head 
in vertex presentation. The bag of 
waters projects to quite an extent 
into the vagina, sometimes forming 
an elongated tumor. Now and then 
the tension is so great that rupture 
occurs with a loud report, on the 
same principle as the bursting of a 
paper bag full of air. As the cervix 
does not perfectly grasp the pre- 
senting part, nearly all of the am- 
niotic fluid is lost after the mem- 
branes are ruptured. When this 
discharge is very rapid, the pains 
often decrease or cease entirely for 
the time being. Meconium is often 
mixed with the fluid. In palpating 
the presenting part we encounter a 
soft, smooth, somewhat conical sur- 
face. If we assume this to be the 
head, we are unable to recognize 
sutures, fontanelles, or hair. If we 
assume that we have a breech pre- 
sentation, we may be able to recog- 
nize the anus, the ischial tuberosi- 
ties, and the tip of the coccyx, 
above which is the triangular sac- 
rum. As labor advances the geni- 




Fig. 



737. 



-Moulding of Skull. — (Author's 
collection.) 



Fig. 7 38. — Moulding of Skull. — (Au- 
thor's collection.) 



FETAL DYSTOCIA FROM FAULTY PRESENTATION. 589 

tals may be recognized, but even then an attempt to distinguish the sex is by- 
no means easy. The anus will feel like a dimple between two skin-covered 
elevations. The buttock will feel like a soft, round tumor, through which the 
great trochanter will offer its resistance. If the tip of the coccyx be felt, the 
examining finger can trace back its connection with the sacrum. The ischial 
tuberosities and the external genitals also present other important landmarks. 
The tip of the coccyx always points away from the back of the fetus. The heels 
and toes also, when the two feet present, will indicate the position of the fetus. 

Differential Diagnosis. — Face and Breech: Great care must be exercised in dis- 
tinguishing a face from a breech presentation, for to the touch the similarity of 
the mouth and the anus may readily lead to an erroneous diagnosis. The anus 
lies in a fossa, while the mouth is more superficially placed. If the finger is 
gently introduced into the cavity, the contraction and resistance of the sphincter 
ani give certain evidence of a breech presentation. Foot and hand: The foot is 
recognized by the presence of the heel and the absence of the adducible thumb and 
by the toes being nearly in a straight line. If the child is alive, the kicking move- 
ments also distinguish between feet and hands. Knee and elbow: The patella in 
the knee can usually be distinguished from the olecranon in the elbow. In 
doubtful cases due to oedema, the part should be followed up to the trunk. The 
groin may be differentiated from the axilla by the absence of the ribs. 

Treatment. — During pregnancy we can often convert the breech into a vertex 
presentation by external version. It will not always be found easy, however, 
to maintain the latter presentation. A common method of accomplishing this is 
to apply two long cylindrical compresses of gauze to the sides of the uterus and to 
hold them in place with a firm abdominal binder. I gave this method a thorough 
trial in the case of a physician's wife, and each removal of the binder resulted in 
a return to a breech presentation. External version, however, is more often 
successful in the beginning of the first stage, the fetus then being manually held 
in the vertex presentation until engagement occurs. I have succeeded with 
this method in several instances after labor has begun. 

Successful treatment can be obtained only by a careful study and appreciation 
in each case of the particular mechanism of labor and of the conditions under 
which the life of the fetus is placed in danger. It should be remembered (i) that 
labor is tedious, because the buttocks constitute a slow dilator of the cervix, vagina, 
and vulva; (2) that the compressible trunk imperfectly dilates the passages, leav- 
ing much for the after-coming hard, incompressible, and relatively large head to 
accomplish in the way of dilatation ; (3) that the real dangers begin when the um- 
bilicus enters the pelvis, and are increased manifold when the umbilical cord and 
head occupy the pelvis at one and the same time. The principles in the treat- 
ment of pelvic presentation are : ( 1 ) To prolong the first stage of labor. This is to 
secure full dilatation of the passages. We accomplish this by discouraging the 
use of the voluntary forces and by the use of chloroform if necessary. (2) To pre- 
serve the membranes as long as possible. This also has for its object the securing 
of a full dilatation. To accomplish this, we make few examinations and keep 
the patient as quiet as possible in the recumbent position. The Germans 
recommend hydrostatic bags or tampons in the upper part of the vagina, but 
I have failed to appreciate their utility. The preservation of the membranes 
is of especial value in breech presentations, because the breech cannot 
well dilate the cervix, for the later passage of the firmer and harder head. 
The soft parts are frequently lacerated by the after-coming head when the 
breech has borne the brunt of dilating the cervix. (3) Carefully to watch the 
fetal heart-sounds after the rupture of membrane and to prepare for a rapid 



590 PATHOLOGICAL LABOR. 

second stage. To have everything ready for the resuscitation of an asphyxiated 
child and to keep the position of the fetus, the mechanism of head expulsion, 
and the dangers clearly in mind. (4) Always to follow down the fundus. This 
preserves head flexion and keeps the uterus closely applied to the head, thus pre- 
venting extension of the arms. (5) To protect the perineum as in vertex cases. 
(6) When the umbilicus appears, to draw down the cord a few inches, to place it 
to the rear, if possible opposite a sacro-iliac joint, to watch its pulsations and to 
protect it from longitudinal stretching. (7) To wrap the child in a hot towel 
(ioo° F.) to prevent respiration from contact with the air of the lying-in room 
(70 F.) and to support it well to prevent pressure on the neck. (8) As the 
chin appears, to elevate the trunk and to assist in the expulsion of the head 
if necessary by suprapubic pressure {expressio foetus). Much can be done at 
this time by urging the woman to use her voluntary muscles in bearing-down. 
If there is much delay, one should not hesitate to employ some form of manual 
extraction of the head. (See Obstetric Surgery, Part X.) Should the arms be- 
come extended along the side of the head or above it, they must be immediately 
brought down. (See Operations, Part X.) Should the head remain transverse 
at the pelvic outlet, two fingers should be placed on the occiput and two fingers 
on the malar bones, or one finger in the mouth, and, the trunk being supported 
between the forearms, the chin should be rotated to the posterior pelvic wall 
(See Part X). The trunk should not be twisted under any circumstances, in the 
hope of causing internal rotation of the head. Should the head remain in a 
transverse position in the upper portion of the pelvis, the head should be 
brought to the pelvic floor by suprapubic pressure and then the above proce- 
dure followed. That the life of the child may be saved the head must be born 
within eight minutes after the appearance of the umbilicus. Sometimes the 
placenta is detached too easily, likewise endangering the life of the child. 
Hence it is necessary to aid the birth of the head. If head flexion is not pre- 
served, the chin will catch somewhere in the pelvis. The flexion should be 
maintained by firm continuous pressure on the fundus of the uterus. In case 
there is prolapse of the cord, the rapid delivery of the child is indicated. If the 
heart-beat is rapid or slow, speedy birth is imperative. If the leg or foot presents, 
it is easy to hurry the labor; but if the breech presents, the acceleration is more 
difficult. It can be done by passing the finger over the groin and making trac- 
tion. Some claim that as soon as the diagnosis is made one should pull down 
one or both legs. One advantage of not doing so is that the breech is a better 
dilator of the cervix than is the body with the legs extended, and, generally 
speaking, it is better to leave the presentation as it is, for fear that leg traction 
might extend head and arms. The first stage of labor should be entirely finished 
before the second stage begins. We should not interfere without some positive 
indication. The forceps is seldom, if ever, required to deliver the after-coming 
head in breech presentation. (See Operations, Part X.) 

XL SHOULDER PRESENTATION. 

Synonyms: Trunk Presentation; Transverse Position; Cross-birth. 

Definition. — Shoulder presentation is so named from the shoulder being the 
presenting part. An absolute transverse position exists when the long axis of 
the fetus forms a right angle with the long axis of the uterus, and is of rare 
occurrence. It is never present during labor. Any position of the fetus in which 
an angle exists between the fetal and uterine long axes is technically a transverse 
position, therefore oblique is really the proper term to designate the anomaly. 



FETAL DYSTOCIA FROM FAULTY PRESENTATION. 



591 



FIRST SHOULDER POSITION. 
LEFT SCAPULA ANTERIOR, L. SCAP. A. 




Fig. 739. — At the Pelvic Inlet. 



Unless the obliquity is so slight that the ordinary head and breech positions are 
assumed spontaneously or through artificial aid during labor, a transverse or 
oblique position is virtually one in which the shoulder presents. These positions 
are, therefore, usually classified with respect to the special attitude of the shoul- 
der. In shoulder presentation the shoulder almost invariably becomes anterior, 
and presents in the cervix or vagina at an early stage of the labor, since it is the 
most prominent and resistant part of the trunk. This is due to the contractions 
of the uterus at the beginning of labor, 
although it is conceivable, and even 
likely, that any of the numerous so- 
called trunk presentations should per- 
sist. Under the term shoulder presenta- 
tion, then, we include all existing trunk 
presentations, such as dorsum, lateral 
plane, abdomen, thorax, neck, arm, el- 
bow, or hand. The commonest form of 
shoulder presentation is the dorso-ante- 
rior, with the head to the left. Occasion- 
ally in this connection we have a com- 
pound presentation, such as hands and 
feet or feet and head. In all cases of 
shoulder presentation a wedge is formed, 
its base pointing upward, made of one of 
the long diameters of the head (4^ to 5! 
inches — 11.43 to 13.97 cm.), and an ob- 
lique diameter of the trunk (4} inches — 
12 cm.) occupying the lower uterine seg- 
ment (Fig. 739). Labor consequently 
with a full-term child and a pelvis of 
average dimensions becomes impossible 
without either spontaneous or artificial 
correction of the malpresentation. 

Frequency. — The proportion of 
shoulder presentations as given by dif- 
ferent statistics varies considerably. At 
one maternity the ratio may be 1 to 125 
normal births, while at another it may 
not exceed 1 in 300. The proportion of 
primiparas to multiparas also varies, the 
former comprising 6 to 27 per cent, of 
the total. In 2200 cases of confinement 
I found shoulder presentation occurring 
in 12 cases, 0.54 per cent., or 1 in 183 
cases. 

Etiology, — This differs entirely with 
the parity of the woman. In primigravidas the pelvis in shoulder presentations 
is usually contracted. As occasional contributory factors may be mentioned 
various conditions which predispose to faulty positions in general — hydramnios, 
monstrosities, malformation of the uterus, twins. In multigravidae shoulder pre- 
sentations often come about through relaxation of the abdominal walls, and 
especially in pendulous abdomen. The causes mentioned as obtaining in primi- 
gravidae are also operative here to some extent. Unusual mobility of the fetus 




Fig. 740. — At the Pelvic Inlet. 




Fig. 741. 



-Right Shoulder in the Cer- 
vix. 



592 



PATHOLOGICAL LABOR. 



SECOND SHOULDER POSITION. 
Right Scapula anterior, R. Scap. a. 




Fig. 742. — At the Pelvic Inlet. 



is another condition believed to favor the persistence of the oblique position. 
In the fetus immaturity — by reason of the weak muscles, the relatively large 
amount of liquor amnii, and the shape of the fetal ellipse in the premature fetus — 
is the great cause of shoulder presentation. (Page 473.) Death and maceration 
of the fetus and multiple pregnancy for like reasons are causes. (Page 473.) In 
the parturient tract pelvic deformity, excessive pelvic obliquity, and excessive 
right lateral obliquity of the uterus are causes by interfering either with the proper 

attitude of the child or the ready en- 
gagement of the head in the pelvic inlet. 
For the same reason placenta praevia, 
lax abdominal walls, as in hanging belly, 
and an excessive amount of liquor amnii 
may result in shoulder presentation. 
This malpresentation is seven times more 
frequent in multigravidae than in primi- 
gravidae. Hydrocephalus or enlarge- 
ment of the fetal head from any cause, 
since then it cannot engage in the pelvic 
inlet; fetal monstrosities and extreme 
mobility of the fetus from any cause; 
tumors of the pelvis or uterus, kyphotic 
spine and exostoses of the pelvic bones ; 
tight lacing during pregnancy, which de- 
creases the depth of the uterus while in- 
creasing the width ; jars or traumatism of 
any kind — any one of these may offer 
cause for this faulty presentation. 

Positions and Relative Frequency. — 
Shoulder positions are named from the 
relation which a scapula — part of the 
fetus — bears to one of the four cardinal 
points of the pelvis. It should be re- 
membered that right and left never refer 
to the scapulas, but always to the right 
and left side of the pelvis ; thus in the 
right scapula anterior we mean that the 
scapula is to the mother's right and an- 
terior, no consideration being taken of 
the fact that the left scapula of the fetus 
presents. 

I. Left scapula anterior, Scapula 
laeva anterior, L. Scap. A. (Fig. 739). 

II. Right scapula anterior, Scapula 
dextra anterior, R. Scap. A. (Fig. 
742). 

III. Right scapula posterior, Scapula dextra posterior, R. Scap. P. (Fig. 745). 

IV. Left scapula posterior, Scapula laeva posterior, L. Scap. P. (Fig. 748). 
Left scapula anterior is the most frequent position. 

Mechanism and Course of Labor.— We may say there is practically no mech- 
anism of labor in shoulder presentation. It is safer to look upon labor as im- 
possible without artificial aid than to trust to a spontaneous termination of the 
complication. The usual steps in unaided cases are impaction of the shoulder; 




Fig. 743. — At the Pelvic Inlet. 




Fig. 744. 



-Left Shoulder in the Cer- 
vix. 



FETAL DYSTOCIA FROM FAULTY PRESENTATION. 



59', 



THIRD SHOULDER POSITION. 
Right scapula posterior. R. Scap. p. 




Fig. 745. — At the Pelvic Inlet. 



ascension of the contraction ring; fetal death from prolonged pressure and 
maternal death from rupture of the uterus or exhaustion. While this is true, 
still under certain conditions a shoulder presentation has been known to terminate 
spontaneously, in three ways, viz.: (1) Spontaneous rectification or spon- 
taneous version; (2) spontaneous evolution; (3) doubled fetus, partus condu- 
plicato corpore. 

1. Spontaneous Rectification and Version. — The term spontaneous rectifica- 
tion is usually confined to instances in 

which the cephalic extremity of the fetus 
is brought into the lower uterine seg- 
ment, and the term spontaneous version 
to those cases in which the breech is 
brought to the pelvic inlet. Spontaneous 
rectification is of frequent occurrence, 
and is often observed in the latter part 
of gestation or in the preparatory or first 
stage of labor. Spontaneous version is of 
less frequent occurrence, as the breech 
is not so frequently substituted for the 
shoulders at the pelvic inlet as is the 
head. The requirements for spontaneous 
version are a rigid fetus, viz., living and 
strong; irregular and strong uterine con- 
tractions, confined to the fundus, where- 
by the breech is driven down into the 
lower uterine segment. Spontaneous 
version is most apt to take place in mul- 
tiparas whose tissues are lax. After the 
bag of waters has ruptured, spontaneous 
version is seldom encountered, although 
the phenomenon is sometimes seen im- 
mediately after rupture before the am- 
niotic fluid has escaped to any great ex- 
tent. When the waters have mostly 
escaped, the tendency of the uterus is to 
grasp the fetus firmly, so that the shoul- 
der presentation becomes confirmed. The 
opposite phenomenon is sometimes seen, 
in which a normal position of the child 
becomes transformed by uterine contrac- 
tions into a shoulder presentation. These 
so-called secondary shoulder positions 
are of very infrequent occurrence. Spon- 
taneous rectification and version are 
both probably due to uterine contrac- 
tions, but another factor assists, such as the antero-lateral pressure of the patient's 
thighs as she sits or throws herself into certain postures, e. g., kneeling or 
sitting. After spontaneous version or rectification has occurred, the mechanism 
is that of a head or breech presentation. 

2. Spontaneous Evolution (Fig. 751). — When a shoulder presentation be- 
comes confirmed, a favorable termination of labor is still possible if the pelvis is 
ample, the pains are strong, and the fetus is small. In these cases the shoulder, 

38 




Fig. 746. — At the Pelvic Inlet. 



i 



Fig. 747. 



-Right Shoulder in the Cer- 
vix. 



594 



PATHOLOGICAL LABOR. 



FOURTH SHOULDER POSITION. 
LEFT SCAPULA POSTERIOR, L. SCAP. P. 




forced into the pelvic inlet, follows the general law of rotation and turns forward. 
It then comes to lie beneath the symphysis, the two fetal poles being closely 
approximated. The shoulder is followed by the subjoined half of the thorax, the 
buttocks, the opposite shoulder, and finally the head. This process may require 
but very little time, and even a solitary contraction is known to have been suf- 
ficient. This spontaneous termination of shoulder presentation occurs in about 
8 per cent, of all cases if unusually small children, second twins, premature 

births, etc., are included. In a series of 
immature living children the proportion 
is still higher, and some authors do not 
even class these deliveries as patholog- 
ical. The stages , then , in the accomplish- 
ment of spontaneous evolution are : ( i ) 
compression of the fetus; (2) descent 
(Fig. 751); (3) engagement of the an- 
terior shoulder under the pubic arch 
(Fig. 752) ; (4) driving out of the podalic 
extremity of the fetus over the posterior 
wall of the parturient tract (Fig. 753); 
(5) delivery of the posterior shoulder and 
arm (Fig. 753) ; (6) delivery of the after- 
coming head (Fig. 754). Excessive lat- 
eral flexion of the fetus is necessary for 
the accomplishment of spontaneous evo- 
lution. Unless all conditions are most 
favorable for birth, the case will end in 
fetal impaction and death of the fetus. 

3. Doubled- Fetus {Partus Condu- 
plicato Cor pore). — When spontaneous 
evolution occurs in very small yielding 
fetuses, the approximated head and but- 
tocks may pass through the pelvis side 
by side, rotation failing to occur. This 
so-called partus conduplicato corpore is 
extremely rare. The fetus's head and 
body together enter the pelvis with the 
prolapsed shoulder in advance. There 
should be rotation of this shoulder to the 
pubic arch, but the mechanism of this 
process is scarcely noticeable, since if it 
is possible for it to take place at all, the 
fetus must be very soft and small. In 
this process the head and body are de- 
livered together, followed by buttocks 
and legs, the second arm lying between 
the head and breech. The conditions 
necessary for delivery by a doubled fetus are a roomy pelvis and a small, macer- 
ated, dead or premature fetus. It is an extremely rare termination. 

The preceding terminations of shoulder presentation are exceptional, and in 
the great majority of cases nature is unequal to the task of expelling the fetus. 
If labor in a shoulder presentation begins with weak pains and early rupture of the 
membranes, the contractions remaining feeble after the latter event, such a state 



Fig. 748. — At the Pelvic Inlet. 




Fig. 



749-- 



At the Pelvic Inlet. 



Fig. 750. — Left 




in the Cer- 



FETAL DYSTOCIA FROM FAULTY PRESENTATION. 595 

of affairs may persist for days 
until the cervix is fully dilated. 
Or we may sometimes see rup- 
ture of the membranes followed 
by violent contractions which 
cause rupture of the lower seg- 
ment of the uterus within a few 
hours. Under any circumstances 
the long sojourn of the fetus in 
the maternal passages, often in- 
evitable in shoulder presenta- 
tion, is frequently followed by 
maceration, especially when 
death has occurred early in 
labor. Maceration, by rendering 
the child more compressible, is 
sometimes the occasion of spon- 
taneous ending of labor. 

Diagnosis. — Before labor ab- 
dominal palpation usually ren- 
ders the diagnosis simple. Dur- 
ing labor we find the cervix 
high up in the pelvis and 
irregular formation of the bag 
of membranes. When uncer- 
tainty exists, one must admin- 
ister chloroform and pass the 
whole hand into the vagina to 
make a positive diagnosis. The 
shoulder is to be differentiated 
from the breech (page 589); the 
elbow from the knee (page 589) ; 
the hand from the foot (page 
589). Inspection alone will often 
reveal the nature of the case, as 
the transverse diameter of the 
uterus exceeds the longitudinal 
and the outline is not symme- 
trical. As a rule, the fetal back 
lies anterior. Then the round, 
hard head can be felt in one iliac 
fossa and the soft, irregular 
breech in the opposite side of 
the mother's abdomen high up 
(Fig. 206). The line of the back 
may be traced between the two. 
These points may be observed 
before labor or in its early stage. 
But at a more advanced stage, 
as lateral flexion of the child in- 
creases, the head would almost 
appear to join the breech at a 







Figs. 



75 1 



Fig 

to 754.— The 

TANEOUS 



Four 
Evoluti 



Stages of Spon- 

ox. 



596 



PATHOLOGICAL LABOR. 



right angle. When the resisting back lies posterior, it cannot be felt by palpation. 
By vaginal examination the dependent part of the bag of waters gives a sensation 




Fig. 755. — Frozen Section of a Neglected Shoulder Presentation. Woman died in 
the second stage of labor. Shows first stage of spontaneous evolution. — (Chiara.) 

often likened to that of a glove-finger ; the head cannot be felt ; if the shoulder 
presents, its rounded contour may be felt as well as the axillary fossa; the ribs 
may be traced near at hand and also the acromion, clavicle, and scapular spine. 



Position of Fetus. 



Left Scap. -ante- 
rior. L.Scap.A. 

Right Scap. -ante- 
rior. R. Scap. 
A. 

Right Scap. -pos- 
terior. R. Scap. 
P. 

Left Scap. -poste- 
rior. L. Scap. 
P. 



Head in left iliac fossa, back anterior; extremi- 
ties on right side, in upper part of abdomen. 

Head in right iliac fossa, back anterior; ex- 
tremities on left side, in upper part of abdo- 
men. 

Head in right iliac fossa, back posterior; ex- 
tremities on left side, in upper part of abdo- 
men. 

Head in left iliac fossa, back posterior; extremi- 
ties on right side, in upper part of abdomen. 



Position of Fetal Heart- 
sounds. 



Left side of abdomen, 
below umbilicus. 

Right side of abdomen, 
below umbilicus. 

Right side of abdomen, 
below umbilicus to- 
ward the rear. 

Frequently cannot be 
heard. Left side to 
the rear. 



Prognosis. — In cases left to themselves the prognosis is grave for both mother 
and child. With intervention, the outlook varies with the stage of labor and 

other factors. If the case is seen 




Fig. 756. — Neglected Shoulder Presentation. 
Left Scapulo-anterior Position. Death of 
fetus and oedema and excoriation of the right 
shoulder. — (Schaeffer.) 



the performance of embryotomv. 



early, the position may be trans- 
formed from the oblique to the ver- 
tical, especially if the bag of waters 
is intact ; while if the latter can be 
preserved until the cervix is fully 
dilated, there is a good chance of 
extracting the child alive. The 
outlook for the mother is prejudiced 
only by the added danger from 
atonia, hemorrhage, and infection 
from manipulations. It must be 
remembered, however, that rup- 
ture of the uterus may occur during 
The prognosis will depend on the operation 



FETAL DYSTOCIA FROM FAULTY POSITION. 597 

undertaken, since natural terrnination of shoulder presentation is not the rule. 
When the presentation is rectified early, there is a good outlook for mother and 
child. Neglected cases will result in death of both. Dangers to the child come 
from compression of the brain centers, vessels of the neck, or umbilical cord. 
Injury of the child is liable to occur during operation. The mother may die of 
sepsis, exhaustion, rupture of the uterus, or hemorrhage. Conclusions: The 
prognosis depends upon: (i) the stage of labor at which the complication is 
recognized; (2) the time that elapses before the correction of the mal- 
presentation ; (3) the time that has elapsed since the membranes ruptured, and 
the quantity of liquor amnii still remaining in the uterus; (4) the condition 
of the uterus and cervix, especially as regards thinning of the lower uterine 
segment, and ascent of the contraction ring; (5) prolapse of the cord as a com- 
plication. A neglected shoulder presentation results in a gradual escape of all 
the liquor amnii, contraction and retraction, a tetanic or inert condition of 
the uterus with or without uterine rupture, exhaustion, and death of both mother 
and fetus. 

Treatment. — All delay is dangerous, and the sooner the malp resent ation is 
corrected by external, combined, or internal version, the better the prog- 
nosis. If the shoulder is already impacted, decapitation of the fetus must be 
performed or some other method of removing the child should be undertaken at 
once. Laparotomy, with the Caesarean or Porro operation, is certainly safer in 
many neglected cases than a difficult decapitation. (See Part X.) 



FETAL DYSTOCIA FROM FAULTY POSITION. 

XII. PERSISTENT OCCIPITO-POSTERIOR POSITION. 

Definition. — The vertex presentation in which backward rotation of the 
occiput occurs in the first and second positions or in which a permanent occipito- 
posterior position obtains in the third and fourth positions. As a rule, labor is 
prolonged in these cases, partly because the head does not flex as it ought to on 
its entrance into the pelvis, and consequently does not readily descend, and 
partly on account of the protracted internal rotation (Fig. 758). 

Frequency. — This is variously stated as from 1 to 4 per cent. In 2200 labors 
I found that persistent occipito-posterior position occurred in 89 cases, or 4.04 
per cent.; 46, or 51.68 per cent., were in primiparae; 33, or 37.07 per cent., in 
multiparas; and 10. or 11.23 per cent., were of unknown para. 

Etiology. — The most common cause is incomplete flexion of the head whereby 
some other part of the head, such as the forehead, first meets the resistance of 
the pelvic floor, and is deflected anteriorly. This throws the occiput into the 
hollow of the sacrum. In other cases the cause may be found in a defect in the 
resistance of the pelvic floor, as in the birth of the second twin when the pelvic 
floor has been stretched by the birth of the first ; in old and extensive lacerations 
of the pelvic floor; in disproportion between the head and floor, as in vers" roomy 
pelves, or in undersized heads; in uterine and abdominal inertia; in obstruction 
to forward rotation of the vertex, as in prolapse of the hand or foot anteriorly; 
in pelvic deformity, as in justo-minor or kyphotic pelves; or in hydrocephalus of 
the fetal head. In these cases accommodation or adaptation results in a pos- 
terior position of the vertex. Sometimes in cases in which there is a slight 
disturbance of flexion and the occiput first touches the floor, there is rotation 



598 



PATHOLOGICAL LABOR. 




Fig. 757. — Diagram Explanatory of the Mechanism of 
Persistent Occipito-posterior Position of the Ver- 
tex. 



backward of the occiput because the fronto -occipital diameter engages and it is 
impossible for the head to rotate from one oblique diameter through the shorter 
transverse to the other oblique. 

Mechanism. — (Compare Vertex Presentation, Part IV.) To understand 

the mechanism of labor, 
careful comparison must 
be made between the lower 
anterior and posterior wall 
of the parturient tract. 
The anterior wall of the 
pelvis, namely, the sym- 
physis, is i| inches (3.81 
cm.) to 2 inches (5.08 cm.). 
The distance from the junc- 
tion of the neck with the 
trunk to the vertex is about 
3 inches (7.62 cm.), hence in 
occipito-anterior position 
the head reaches the pelvic 
floor and extends through 
the vulval orifice without 
the trunk necessarily en- 
tering the pelvis until the 
head is completely deliver- 
ed. The posterior wall of 
the pelvis, from promon- 
tory to sacrum of coccyx, 
is 5 inches (12.7 cm.), and the pelvic floor, when distended, from coccyx to edge 
of perineum is also 5 inches (12.7 cm.), making 10 inches (25.4 cm.) from pro- 
montory to perineum. Hence for the vertex to reach the pelvic floor in the pos- 
terior position the neck must be greatly elongated or the trunk must enter the 
pelvis with the head. If the latter 
occurs, subsequent impaction is liable 
to take place, for we will then have at 
the pelvic outlet a presenting part whose 
antero-posterior diameter is made up of 
the fronto -mental diameter of the fetal 
head ($\ inches — 8.25 cm.) and the 
dorso-sternal diameter of the fetal trunk 
(3I inches — 9.5 cm.), making together 
7 inches (17.78 cm.) to pass through the 
lower part of the pelvis (Fig. 758). In 
spite of the foregoing, spontaneous ter- 
mination sometimes occurs. The brow 
engages under the symphysis ; the peri- 
neum, tremendously distended, retracts 
over the occiput; the latter, in an ex- 
treme state of flexion, sometimes with 

an entire loss of perineum and anterior rectal wall, extends and is born. 
The nape of the neck then rests upon the retracted and lacerated peri- 
neum and the supraorbital ridges, eyes, nose, and mouth appear under the 
symphysis and the head is born by extension. Persistent occipito-posterior 




Fig. 



758. — Persistent Occipito-poste- 
rior Position. 



FETAL DYSTOCIA FROM FAULTY POSITION. 



HEAD MOULDING IN PERSISTENT OC- 
CIPITO-POSTERIOR POSITION. 



^ 



,*-*fc«Jr 







position is also known as "face to pubis." When natural expulsion takes place, 
as has been said, the face passes under the symphysis and the occiput makes its 
way over the perineum. This process is not an easy one and necessitates vigorous 
contractions, lax maternal soft parts, and head of ordinary size. The head mould- 
ing results in very much shorter occipito-frontal and occipito-mental diameters 
with corresponding lengthening of the 
suboccipito-bregmatic (Fig. 760). Be- 
fore passing through the outlet the 
head becomes well flexed. After the 
head is born external rotation (in- 
ternal rotation of the shoulders) oc- 
curs, after which the body is born. If 
flexion be prevented, the head may 
rarely come down into the pelvis in a 
state of extension and there exists a 
brow or face presentation. Or, again, 
the head only partially flexed may 
enter the pelvis, and after reaching 
the floor there may be partial rotation 
and the head become fixed in the 
transverse diameter of the cavity of 
the pelvis, (Deep Transverse Position 
of the Head, page 608.) 

Diagnosis. — In palpation of the 
maternal abdomen at the beginning 
of labor the fetal limbs but not the 
back may be felt, especially if the 
parietes are lax and thin, and the head 
may be perceptible above the brim. 
The heart-sounds are heard between 
the ribs and the crest of the ilium. 
By vaginal examination the head 
may be felt through the fornices, and 
later on, when the cervix is sufficiently 
dilated, the posterior fontanelle is in 
the posterior part of the pelvic cavity, 
while the sagittal suture is in the line 
of an oblique diameter. In the first 
stage the pains are not infrequently 
irregular and abnormal. 

Prognosis. — The dangers to the 
mother are prolonged labor, exhaus- 
tion, and even death. Severe lacer- 
ations of the pelvic floor are the rule. 
In impaction pressure necrosis, sepsis, 
and shock of operation may occur. 
The mortality for the child is about 

10 per cent. The dangers are: asphyxia from prolonged compression or prema- 
ture separation of the placenta; cerebral compression, and pressure on the cord. 

In my 89 cases already referred to, the maternal mortality was 3 cases, or 
3.38 percent. Regarding the fetal prognosis, 79, or 88.76 per cent., lived; 7, or 
7.86 per cent., were still-born; and the result for 3, or 3.38 per cent., was not 



Fig. 



759- 



-Before Moulding. 




Fig. 760. — After Moulding. Note depres- 
sion at anterior fontanelle caused by the 
pubic arch. 



600 



PATHOLOGICAL LABOR. 



recorded. In the 89 cases referred to above, the method of delivery was by 
natural forces in 43 cases; forceps in 41 ; version in 2 ; craniotomy in 1 case, and 
symphyseotomy in 1 case. 

' .^Treatment. — Prophylactic : The preventive treatment of this quite com- 
mon and serious complication of labor promises very little indeed, because 
we are unable to remedy the anatomical cause of the condition found in 
the fetus, pelvis, or maternal soft parts. When the diagnosis of occipito- 
posterior position is made in pregnancy, it has been proposed that the 
more favorable anterior position shall be obtained by external manipulation 
through the anterior abdominal wall. This is a refinement of abdominal 

palpation which I believe to be 
theoretical in the hands of most, 
if not all, obstetricians. Postural 
prophylaxis, on the other hand, I 
believe offers some hope in cases in 
which the anatomical influences in 
fetus, pelvis, or maternal soft parts 
are not too strong. In instances 
in which there is reason to suspect 
this complication the patient may 
be instructed to assume the knee- 
elbow position for five or six min- 
utes morning and evening for a 
fortnight or even longer preceding 
labor.* This to be followed by the 
lateral posture. I have found in 
private practice that it is often a 
physical impossibility for patients 
to remain more than a minute or 
two in the knee-chest position by 
reason of the intense cerebral con- 
gestion and discomfort produced. 
In such a case in the latter part 
of pregnancy and during the first 
and second stages of labor I have 
the woman placed in an exagger- 
ated lateral prone position with a 
pillow or several sheets under the 
lower buttock in order, as far as 
possible, to reverse the condition of the dorsal position. The choice of side for the 
patient to lie upon is the one toward which the occiput points. (See Operations, 
Part X.) Operative: It should be clearly understood that operative interference in 
oecipito-posterior position is not to be undertaken until labor has advanced to a 
point at which the interests of fetus or mother demand intervention. It must be 
remembered that operation is applicable only to persistent cases of this kind ; that 
most of the originally oecipito-posterior positions terminate anteriorly spontan- 
eously, and that only between one and four per cent, of all vertex positions result 
in persistent posterior positions, the remaining being either originally anterior 
positions or terminating spontaneously as such. Before deciding upon inter- 
ference in all cases of delayed labor at the pelvic inlet I always make a thorough 
examination under ether, introducing the whole hand if necessary to ascertain 
* Reynolds: "Practical Midwifery," page 211, 1892. 




Fig. 761.— Persistent Occipito-posterior Po- 
sition of the Head. R. O. P. Prolonged labor; 
secondary inertia; rest; strychnia; spontane- 
ous delivery with anterior rotation of the oc- 
ciput. — {From a tracing. Emergency Hospital, 
October 7, 1892.) 



FETAL DYSTOCIA FROM FAULTY POSITION. 601 

the presentation and position, and secure flexion or extension as the case may be. 
For convenience' sake I am accustomed to divide all of these cases into three 
classes: (i) High cases, in which the vertex is still above the pelvic inlet and 
not engaged; (2) medium, in which the vertex is fully engaged but occupies 
the upper part of the pelvis and has not reached the pelvic floor; (3) low cases, 
in which the occiput rests on the pelvic floor and possibly distends the perineum. 
1. High Cases. — This is the most infrequent of the three classes, for in the 
majority of cases the natural powers possess strength enough to engage the 
head, and only subsequently, by reason of the malposition and excessive 
force required, do the powers fail. Fortunate it is that this is the case, since 
this class carries with it the worst prognosis under operative treatment. No 
serious disproportion existing between the fetus and pelvis, we have at our 
command four procedures for the management of these cases: (1) Rotation of 
the back of the fetal ellipse to the front by external manipulation, followed 
by the application of the forceps; (2) rotation of the vertex from the posterior 
to the anterior position by internal manual means, followed by the use of the 
forceps; (3) the application of the forceps without previous attempts at 
anterior rotation of the occiput ; (4) internal podalic version followed by breech 
extraction. (1) External manual rotation: The possibility under favorable con- 
ditions — namely, intact membranes and thin abdominal walls — of rotation of 
the occiput forward by external manipulation must be granted, but such a 
theoretical refinement of obstetrical palpation can scarcely be of much practical 
value. (2) Internal manual rotation: Anterior rotation of the occiput by means 
of the hand passed into the uterus and grasping the head or shoulders and 
allowing the anterior position to terminate spontaneously, or delivering imme- 
diately with the forceps, is the favorite treatment with many operators in 
America, and by some used to the exclusion of other methods of treatment. 
I have been more successful with other methods, and I am convinced after 
repeated trials that the mortality with this method equals that of internal 
podalic version, for the reason that successfully to carry out the anterior rotation 
the hand must be used not only to rotate the head, else it will immediately 
return to its malposition, but it must be passed up and rotate the shoulders 
as well. This grasping of the fetal body I have found disturbs the circulatory 
equilibrium of the fetus, favors intrauterine asphyxia, and, unless the fetus 
is immediately extracted, intrauterine death ensues. Should this method of 
manual correction be selected, it should always be performed bimanually, 
one hand upon the anterior abdominal wall assisting in the work of the internal 
hand. The operation can often be more readily performed with the patient 
in the exaggerated left lateral prone posture, and lying upon that side of the 
pelvis around the segment of which we desire the occiput to rotate. (See 
Part X.) If the fetal back and occiput are directly to the rear, and there 
is thus no choice of sides for the patient to lie on, the exaggerated left lateral 
prone posture will be found the most convenient for permitting the use of 
the right hand internally. (3) Forceps: The application of the forceps without 
previous attempts at anterior rotation of the occiput. Both theoretically 
and practically I believe this method will give better results as far as fetal 
mortality and morbidity are concerned, and equally good results for the 
mother as version. The difficulties and dangers of a high forceps operation 
in this as in other presentations and positions must ever be kept in mind, and 
so great are these dangers that I would recommend this method of treatment 
only to those thoroughly familiar with the technique of a high forceps operation. 
For those of limited experience in high forceps operations version will prove 



602 PATHOLOGICAL LABOR. 

the safer operation for the mother, although carrying with it a high fetal mor- 
tality. Of course, the usual contraindications for version always hold good — 
namely, escape of the liquor amnii, tetanic uterine contractions, and dangerous 
thinning of the lower uterine segment. It is in these cases particularly that 
no aesthetic reason should prevent our perforating the head of a dead fetus. 
Usually it is not wise to attempt an adaptation of the forceps under such 
conditions to the sides of the fetal head, — namely, the cephalic application, — 
but to apply the instrument at the sides of the pelvis — namely, the pelvic 
application. My object in the use of the forceps in these cases is to change 
a high occipito-posterior position into a medium or low one, then to remove 
the forceps, which has perhaps grasped the head obliquely, adapt it over the 
fetal ears, use the instrument as a rotator, and instrumentally rotate the 
vertex to the front as in medium and low cases. (See Operations, Part X.) 
(4) Version: Manual anterior rotation or forceps without manual rotation failing 
and the fetus being still alive, version remains as the only alternative. I 
place version last because I believe the forceps alone or combined with manual 
rotation offer the best prognosis in the hands of the experienced operator. 
If by reason of uterine retraction version is forbidden, perforation and possibly 
symphyseotomy should be considered. 

2. Medium Cases. — As in high cases of persistent occipito-posterior posi- 
tions, the first step in the treatment is to insure complete flexion of the head. 
Anterior rotation may be promoted by pressure upon the forehead applied 
during a pain. This pressure should be applied as far forward as possible. 
If the head becomes extended, it may be flexed by pushing up the forehead 
or pulling down the occiput. For the latter purpose a vectis or blade of the 
forceps may be used if there is no room for the hand. If the expulsive force is at 
fault, the judicious use of remedies for delay in the second stage may be employed 
(page 630). If all efforts at rotation fail and immediate delivery is demanded, 
the application of the forceps is the only resource, short of perforation. (For 
the use of the forceps in occiput posterior positions see Operations, Part X.) 

3. Low Cases. — This I have found to be the most frequent variety of occipito- 
posterior cases met with. The forces are able to push the fetal head to the 
pelvic floor, and then delayed labor ensues by reason of the fact that the forceps 
is unable either to rotate the occiput anteriorly or to deliver the head of the 
occiput remaining at the rear. Whether the case be a left or right s aero -position, 
two methods of delivery in the case of a living fetus are open to us. These 
are (1) forceps delivery with the occiput still posterior; and (2) rotation of the 
occiput anteriorly with the forceps and delivery as in anterior positions of the 
vertex. In all cases with the exception of a few multiparse with lacerated and 
relaxed pelvic floors in which little resistance to delivery is offered I would 
advise the second plan of procedure, — namely, anterior rotation of the occiput 
with the forceps,— for the reasons that less laceration of the pelvic floor occurs, 
and the fetal morbidity and mortality are less in mechanical anterior rotation 
and delivery. Much bitter opposition to instrumental rotation of the present- 
ing part has been expressed by English and American obstetric writers, notably 
Playfair,* Lusk,f Hirst, J and Reynolds?; the French and German writers 
taking a more liberal view of the question. Since the early nineties I have 
been teaching and using instrumental rotation in these cases in both hospital 

* " Science and Practice of Midwifery," 1898. 
f " The Science and Art of Midwifery," 1892. 
% "Text-book of Obstetrics," 1898. 
§ " Practice of Midwifery," 1896. 



FETAL DYSTOCIA FROM FAULTY POSITION. 



603 



and private work, and, with certain limitations, have never had occasion to 
regret it. A paper by Brodhead,* of New York, read before the New York 
Obstetrical Society, brought out in the discussion that the method, in New York 
at least, was coming into general favor; Cragin, Tucker, Marx, Von Ramdohr, 
and I indorsing the operation. (See Operations, Part X.) 



w essionca^ 

y 




XIII. PERSISTENT MENTOPOSTERIOR POSITION. 

Definition. — A face presentation in which backward rotation of the chin 
occurs in the first and second positions, or in which a persistent mento-posterior 
position obtains in the third and fourth 
positions (Fig. 764). 

Frequency. — Face positions in the pel- 
vic cavity with the chin persistently behind 
are rare ; their existence has even been de- 
nied. They make up less than one per 
cent, of all face positions. 

Etiology. — (1) The face may engage at 
the inlet with the chin behind and anterior 
rotation may not take place; (2) or, with 
the chin in front, posterior rotation occurs. 
In the first case the failure of anterior rota- 
tion is due to the relative disproportion be- 
tween the depth of the excavation at the 
side and the length of the fetal neck, so 
that the chin does not meet with sufficient 
resistance to produce anterior rotation. 
Certain pelvic deformities or obstructive 
conditions of the soft parts might produce 
the same results. The prominence of the 
bregmatic region in consideration of the 
distance it must travel in rotation renders 
necessary the presence of strong, persistent 
uterine contractions and capacity of the 
head for moulding. The second variety 
can occur only with a very large pelvis or 
small head; the head is imperfectly ex- 
tended, the sinciput meets with the pelvic- 
floor resistance before the chin and is turned 

forward, carrying the chin backward. In the case of a very small fetal head or 
justo-major pelvis the face may be forced into the pelvis with extension incom- 
plete. The sinciput strikes the pelvic floor in advance of the chin. If the chin 
is behind in the inlet, it remains behind ; if in front, the sinciput strikes the sacral 
segment of the pelvic floor and rotates forward, carrying the chin backward. 

Mechanism. — To understand these unreduced mento-posterior positions we 
must bear in mind the mechanism of normal posterior face positions. These 
presuppose the existence of complete head extension by virtue of which the chin 
is first to strike the pelv'c floor and be rotated beneath the pubis. When 
the etiological elements already enumerated come into play so that the chin 
finds its way to the hollow of the sacrum, the head, neck, and thorax constitute 
a wedge which with further progress of labor becomes impacted. The almost 
* " American Journal of Obstetrics," vol. xlii, No. 6, 1900. 



Fig. 762. — Moulding of the Head in 
Face Presentation. Primipara; 
R. M. P.; first stage of labor three 
days ; membranes ruptured two days ; 
uterine inertia; manual dilatation 
of cervix; adaptation of forceps to 
fronto-mental diameter transverse in 
the pelvis ; rotation with the forceps ; 
delivery of a living child. — {Author's 
case at Emergency Hospital. Decem- 
ber 8, 1902. From a tracing.) 



604 



PATHOLOGICAL LABOR. 



unanimous testimony of obstetricians is that birth of living mature children 
in mento-posterior positions is necessarily impossible. Ahlfeld states that 
a few cases of undoubted authenticity are on record, but does not state how 
such births were made possible. The mechanism of this position in relation 
to its essential fatality may be summarized as follows: Spontaneous expulsion 







V>, 



Fig. 763. — Moulding from Persistent Mento-posterior Position. R. M. P.; prolonged 
labor; secondary inertia; rhythmia; spontaneous delivery with anterior rotation of 
the chin. — {Author's case at the Emergency Hospital, April, 1902.) 

is impossible without partial or complete rotation of the chin forward; the 
length of the fetal neck from the trunk to the chin is about 2 inches (5.08 cm.); 
the posterior wall of the parturient canal from the promontory to the edge 
of the perineum is 10 inches (25.4 cm.); the chin cannot reach the perineum 
without entrance of the thorax into the pelvis; impaction results because 
the trachelo-bregmatic diameter of the head, and dorso-sternal diameter of 




Fig. 764. — Persistent Mento-Posterior Position. 



the thorax, each of which measures 3^ inches (8.89 cm.), or 7 inches (17.78 cm.) 
in all, attempt to pass into the pelvis at once. Naturally all the phenomena 
of obstructed labor result, including tetanoid contractions of the uterus. The 
fetus perishes from asphyxia as a consequence of compression of its head and 
chest. These unreduced mento-posterior positions are often compared with 



FETAL DYSTOCIA FROM FAULTY POSITION. 605 

those in which the occiput does not undergo anterior rotation. In the occipito- 
posterior variety the occiput clears the perineum and frees the head; but in 
the mento-posterior the large fontanelle is pressed against the pubis, and for 
the chin to clear the perineum a degree of extension would be required which 
is impossible for a living, full-sized fetus (Fig. 764). 

Diagnosis. — In a mento-posterior position the occiput is found more 1 toward 
the front in the anterior and lower part of the uterus, palpable and visible from 
the outside. Internally the vaginal vault appears flat and the chin stands high 
and is difficult to reach posteriorly. The fetal cardiac sounds are heard with 
difficulty. With the entire hand in the vagina the diagnosis is not difficult. 

Prognosis. — This position is universally recognized as forming the most 
serious mechanical complication of labor arising from the fetus. The child mor- 
tality is practically 100 per cent., for there are but two or three living births 
on record. The maternal mortality is unknown. No large series of mento- 
posterior cases has ever been compiled. The mother is exposed to great danger 
and the mortality is doubtless high. 

Treatment. — If the faulty position is recognized in time, an attempt 
should be made to determine its cause and to rectify it. The defective extension 
may sometimes be corrected by the finger or hand. Application of the hand 
or forceps blade beneath the chin will give the latter a point of support which 
will favor anterior rotation. Traction with forceps will bring the chin upon 
the pelvic floor and slight rotation will enable it to rotate forward. No attempt 
should ever be made to deliver the chin over the perineum. When the face 
is impacted, the indication must lie between forceps for rotation, symphy- 
seotomy, Caesarean section, and perhaps embryotomy. The original teaching 
of Scanzoni and others that forceps might be used to turn the chin forward is 
now almost universally condemned. Popescul * followed this advice and lost the 
mother. He states that he would never use the forceps in another case. Von 
Braun states that the use of the forceps for this complication means death for 
mother and child. Doderlein appears to think that great technical skill might 
accomplish something with the forceps. Popescul first brought the face into 
the transverse position. He then detached the blades, reapplied them, turned 
the chin under the symphysis, and extracted the child. In the past most 
authorities agreed that perforation is the indication of necessity, even in the 
living child. Symphyseotomy has been suggested as applicable to this com- 
plication, but I do not know that it has ever been done. 

XIV. TRANSVERSE ENGAGEMENT OF THE HEAD IN THE INLET IN 

DEFORMED PELVES. 

This position is also known as the "high transverse position."! It is en- 
countered in the generally contracted or flat pelves, for the latter of which it is the 
characteristic mode of engagement. In this position the bitemporal diameter, 
which measures 3.15 inches (8 cm.), corresponds to the contracted pelvic conju- 
gate. This phenomenon, at first sight an anomaly of the mechanism of labor 
in reality is an attempt of nature to offset the anomaly of the pelvis (Figs. 769 

to 775)- 

Mechanism. — In simple flat pelves: The head having been forced downward 
upon the flattened brim and being free to move upon the neck, assumes the 
direction of least resistance, which brings its longest diameter into the 

* " Centralbl. f. Gynakol.," Aug. 4, 1900. 

f German, die hohe Querstellung oder Qu?r stand. 



606 



PATHOLOGICAL LABOR. 




Fig. 765. — Engagement of the Head in 
a Generally Contracted Pelvis. Ex- 
cessive Flexion. 




Fig. 766. — Engagement of the Head in 
a Generally Contracted Pelvis. Ex- 
cessive Flexion. 



Syfph 




Fig. 767. — Extra-medial Position of 
the Head in a Flattened Pelvis. 



Fig. 768. — Engagement of the Head in 
a Flattened Pelvis. 




-"/ 




Fig. 769. — Presentation of the Ante- 
rior Parietal Bone and Engagement 
of the Head in a Flattened Pelvis. 



Fig. 770. — Engagement of the Head as 
in Fig. 769. 



FETAL DYSTOCIA FROM FAULTY POSITION. 



607 




Fig. 771. — Presentation of the 
Posterior Parietal Bone in 
a Flattened Pelvis. 




*^ 




Fig. 773. — Artificial Engagement of the 
After-coming Head in the Inlet of a 
Generally Contracted Pelvis by Bring- 
ing the Bitemporal Diameter between 
Promontory and Pubes. — {Budin.) 



Fig. 772. — Steps in the Engagement of 
the Head Presenting with the Pos- 
terior Parietal Bone in a Flattened 
Pelvis. 




Fig. 774. — First Step in the Engagement 
of the After-coming Head in the In- 
let of a Flattened Pelvis. Lateral 
Inclination of the Head and Engage- 
ment of the Posterior Parietal Bone. 
— {Budin.) 



Fig. 775. — Second Step of Fig. 774. En- 
gagement of the Anterior Parietal 
Bone. — {Budin.) 



608 PATHOLOGICAL LABOR. 

longest pelvic measurement. The biparietal diameter is unable to follow into 
the short antero-posterior diameter of the contracted brim, so that the occiput 
is arrested at the ilio-pectineal line. The application of the expulsive forces 
now produces extension of the head, with the result that the bitemporal 
diameter may be able to clear the brim if the disproportion between 
it and the narrowed conjugate is not too great. The head may then enter 
the pelvis directly or one parietal bone may precede the other; the anterior, 
as a rule, being the first to clear the brim because of the slight resistance en- 
countered (Figs. 769 to 772). The transverse position of the head may persist 
up to the point of expulsion, as rotation often fails to occur (see following 
section). In generally contracted pelves: The head may assume this position in 
the generally contracted pelvis, but labor is not facilitated thereby. 

Diagnosis. — Vaginal touch reveals the sagittal suture in the transverse 
diameter of the inlet, the posterior fontanelle at one side corresponding to 
the back of the fetus, while the greater fontanelle lies at the opposite end of 
the transverse diameter. The skull is flexed laterally upon the fetal body 
to an extreme degree. Consequently the anterior parietal bone or the ear 
presents (Naegele's obliquity, page 571). The great danger of this condition 
is that, the head having become somewhat extended, the occiput may rotate 
posteriorly after the brow touches the pelvic floor. 

Treatment. — If possible, partial or complete anterior rotation of the occiput 
should be brought about as soon as the inlet is passed, otherwise delivery by 
forceps, version, or symphyseotomy should be performed, the method depending 
on the degree of contraction present. (See Pelvic Deformity.) The application 
of the forceps is extremely difficult and should be undertaken only with the 
greatest care and by one who is fully capable of managing it in this con- 
dition, as injury to the child's face is common. 



XV. TRANSVERSE POSITION OF THE HEAD AT THE PELVIC 

OUTLET. 

Definition and Etiology. — Descent of the head occurs without anterior 
rotation in consequence of certain anomalies of the pelvis or fetus. This is 
the "deep transverse position" of the head. This position is primary or 
secondary. The primary position is found in the simple flat pelvis, in 
the generally contracted flat pelvis, and in the masculine or funnel- 
shaped pelvis, and even in the larger pelves when the head is very 
small and the liquor amnii suddenly lost with precipitate descent of 
the head. It is also found in congenital double hip dislocation. In the 
simple flat pelvis the bregma is lower, while in the generally contracted flat 
pelvis the posterior fontanelle is lower. Nearly all of these cases when analyzed 
show themselves to be occipito-anterior presentations. The secondary position 
is found when the head is large and the occiput is broad, as in dolichocephalus. 
The occiput continues posterior from the first till the head reaches the floor 
of the pelvis. At this point there may occur a partial rotation of the occiput 
into the transverse diameter of the outlet. The bregma is generally lower than 
the occiput. Incomplete head flexion is a common cause. Again, this position 
may occur in case of a flat pelvis which is large enough to let the head pass the 
inlet in an oblique diameter, the occiput being posterior, but wh'ch is so con- 
tracted below that anterior rotation cannot completely take place as in the mas- 
culine pelvis. Reed found 32 deep transverse arrests of the head in 3600 labors 



FETAL DYSTOCIA FROM GENERAL FETAL CONDITIONS. 609 

at the Chicago Lying-in Hospital, or 0.9 per cent.; 18 cases occurred in multi- 
parae and 14 in primiparas (Fig. 776). 

Symptoms. — If the head remains in this position, pressure necrosis, fistula, 
and death of the fetus and mother may occur. The head may be born trans- 
versely, causing extensive laceration, or anterior or posterior rotation may 
take place. In some cases the pains may entirely cease owing to the obstruc- 
tion to labor. In others, the head may be forced through the bony outlet by 
the excessive strength of the pains, and the perineal tissue then suffers. 
Spontaneous transverse delivery may rarely occur in the case of a large pelvis, 
a small head, and an old perineal laceration. Cases are known in which the 
head if it continues in extreme flexion is born transversely in a flat and con- 
tracted pelvis. 

Prognosis. — For the mother, delayed labor, exhaustion, and sepsis; for 
the fetus, asphyxia or death from compression of the brain or placenta. 




Fig. 776. 



-Transverse Position of the Head at the Pelvic Outlet, 
verse Position of the Head. 



Deep Trans- 



Treatment. — Postural treatment offers very little. Anterior rotation may 
be favored by the lateral decubitus, the patient lying on the side toward which 
the occiput faces. (See Posture in Obstetrics, Part X.) Stimulants, such as 
strychnin, quinin, and alcohol, may be administered to increase the expulsive 
forces. Digital rotation with the hope of bringing the occiput forward may be 
tried, but will hardly succeed in contracted pelves: (1) With two fingers in the 
vagina we may attempt to push the sinciput posteriorly; (2) with two fingers. 
or the whole hand in the vagina we may lift up the head slightly and with two 
fingers of the other hand in the rectum attempt to push the brow backward ; 
(3) with the whole hand in the vagina grasping the vault of the head, we may 
attempt both to raise the head from between the tubera ischii and at the same 
time rotate the occiput anteriorly. Failing with manual correction, the forceps 
may be applied in an oblique pelvic diameter and rotation combined with trac- 
tion used. Symphyseotomy has its place in firm impaction and a living fetus. 
In all cases of impaction with a dead fetus the head should be perforated. 



39 



610 PATHOLOGICAL LABOR. 

FETAL DYSTOCIA FROM GENERAL FETAL CONDITIONS/ 

XVI. MULTIPLE BIRTH. 

Definition. — The birth of two, three, or more normal fetuses. Monsters 
are not included under this head. 

Frequency. — The proportion of multiple to single births varies considerably 
in different countries. The ratio of triple, twin, and ordinary labors in Ger- 
many is given by Strassmann as i : 89 : 7921. It is of interest to note that in 
this series the number of twin pregnancies is exactly the square root of the 
number of single births. For the etiology see page 144. 

Symptoms. — The course of multiple delivery is often short. After one 
fetus is expelled the uterus is quiescent for a certain period; upon an average, 
for half an hour. Instead of this physiological repose, however, prolonged 
inertia may develop. In such cases the second child may be in a transverse 
position, and in any case the second membranous sac should be ruptured at 
the expiration of half an hour. The cervix being fully dilated and the cord 
of the first fetus still connected with the placenta, the chances for intrauterine 
infection are considerable. The fetal presentations run as follows in twin labors : 
the commonest form is the double vertex (Fig. 781); next, the fetus to be 
born first presents by the head, the other by the breech (Fig. 783); third, 
the first fetus presents by the breech, the second by the head; fourth, a head 
and a shoulder presentation are associated, the first child usually presenting 
by the head. Two shoulder presentations occur infrequently (Fig. 780), while 
two pelvic presentations are very exceptional. Averaging a large number 
of presenting parts in multiple births it is found that about 54 per cent, 
are cephalic, about 32 per cent, pelvic, while the remainder are shoulder. 
About three-fifths of the heads are in the first, the remainder in the second 
cranial positions. It very seldom occurs that both heads are in the same 
positions. As a rule, the fetuses are face to face, and the one on the left 
side is born first, the right coming after in the second cranial position. If 
the fetuses are placed one behind the other, the heads should be in 
the same position. In regard to abnormal presentation in twin preg- 
nancy, bregma, brow, and face positions occur more frequently than with 
single births, comprising not less than 10 per cent, of cephalic births. Bregma 
presentation is probably increased because of the diminished prominence 
of the frontal region in twins, which reduces the resistance encountered at 
the pelvic inlet. As a rule, brow and face presentations run a more favorable 
course than in single labors. (For diagnosis and prognosis see page 147.) 

Management of Twin Labors. — In the case of abortion of one twin it was 
once the practice to attempt retention of the second, and successes have been 
reported. To-day it is the uniform practice to bring away the sound fetus 
with its dead fellow, for the chance of saving life does not compensate for the 
danger of infection. In women with contracted pelves the occurrence of multiple 
pregnancy is in some respects an actual advantage. It occasionally happens 
that such a woman, after losing a series of normal single children through 
dystocia due to contracted pelvis, has given birth to living twins (I have my- 
self had such a case), and even in cases in which the latter were both in shoulder 
presentation (Strassmann). For this reason it is highly important, before 
inducing premature delivery for contracted pelvis, to obtain the assurance 
of the non-existence of twin pregnancy. Symphyseotomy must never be 
performed unless assurance of a single pregnancy exists. If the diagnosis 




Figs. 777 to 783. — Presentations 
in Twin Deliveries. — (After 
Dickinson.) 



Fig. 783. 



611 



612 PATHOLOGICAL LABOR. 

of twins has been made at any period, the woman should never be informed 
of the fact; she should be told the truth only after the first birth. The leading 
indications for intervention in twin labors vary with the two children. The 
presence of inertia, so common in these births, renders it necessary at times 
to hasten the delivery of the first twin by artificial measures. With its fellow 
it may be necessary to hasten birth by reason of hemorrhage or failure of the 
fetal heart. The necessity for narcosis which often arises during extraction 
of the first child adds to. the likelihood of such indications. As the great ma- 
jority of twin births terminate spontaneously, non-intervention should be the 
rule, especially in vertex presentations. If the inertia is unduly prolonged, 
the membranes should be ruptured at a period somewhat earlier than in single 
births. The first step after the first child has been delivered and the cord 
ligated is to make a vaginal and abdominal examination. If the second fetus 
be found in any but a shoulder presentation, there should be no immediate 
intervention save for causes to be described later, since in most cases delivery 
is easy owing to the dilatation of the birth canal by the first child, and because, 
owing to the danger of post-partum hemorrhage, the rapid emptying of the 
uterus is inadvisable. The uterus should be followed down by the hand during 
the stage of expulsion, and every precaution should be taken against the occur- 
rence of hemorrhage. If the second fetus is found in a shoulder presentation, 
cephalic or podalic version should be performed and extraction effected imme- 
diately unless the version can be accomplished by the external or combined 
methods alone. Post-partum hemorrhage after the first labor is a complication 
to be reckoned with. It must be remembered that tears of the cervix, vagina, 
and perineum are very rare in twin labors, and that the appearance of hemor- 
rhage after the first birth points almost certainly to a placental origin. If 
the placenta is single, the escaping blood is a menace to the child coming after;, 
if double, the second child is not compromised. In any case of uncertain 
diagnosis the second fetus must be given the benefit of the doubt and delivered 
at once. Failure of the fetal heart is an indication for intervention. In the 
case of hemorrhage or other source of danger to the mother or the second infant, 
the latter should be rapidly delivered by forceps or complete version. If 
after an hour or thereabouts from the birth of the first child the uterus does 
not contract, the condition of atony usually demands intervention. Some 
authorities see no harm in waiting as long as three hours if the condition of 
the mother and fetus is favorable. Many cases are on record in which the second 
fetus has remained in utero for several weeks and been delivered in a vigorous 
condition. Hence, if the first child is premature and is followed by its placenta, 
it may be wise to leave the second child in utero, that its chance of ultimate 
survival may be improved. When it is decided to interfere, the membranes 
should be ruptured and massage of the fundus begun. As a rule, all the secun- 
dines are expelled at once after the birth of the second child. Owing to its 
large size, it is often difficult to bring away the placenta by Crede's method. 
There is after twin labors a marked tendency to atony of the uterus which 
demands an extra large dose of ergot and prolongation of the usual interval 
of medical supervision. The likelihood of hemorrhage is naturally increased 
if the twins are expelled in quick succession, as this amounts to precipitate 
labor. In rare cases both placentas are expelled before the birth of the second 
child, which must then be delivered at once to avoid suffocation. In the case 
of unioval twins (with but one placenta) a twisting and entanglement of the 
cords sufficient to retard delivery may occur. In this case it is well to cut 
the cord between two ligatures and deliver at once; or the division of both 



FETAL DYSTOCIA FROM GENERAL FETAL CONDITIONS. 613 

cords may be required. In rare cases the first fetus may be transverse while 
the second is astride of it (Fig. 777). This possibility should be remembered, 
since in such a case traction on the legs of the second would be disastrous. 

Management of Triple Labor. — Labor here is generally easy because of the 
small size of the fetuses. As in twin births, dilatation occurs slowly by reason 
of the inertia of the distended uterus. When expulsion begins, however, 
the labor may be precipitate, each fetus being small and the last two requiring 
no delay for dilatation. Each bag of waters presents and ruptures in turn, 
but the placentae and cords show much variation. Each placenta may 
follow its fetus as in single births; the first two placentae may come away 
after the second child, or all three may follow the third fetus. The interval 
between the labors varies greatly. In a precipitate delivery there is no interval 
and the children may all be expelled in fifteen or twenty minutes. In other 
cases there may be a short interval between the births of the first and second 
fetuses and a much longer one between the second and third, or this may be 
reversed. Apparently the complete uterine repose which occurs between 
labors in a twin pregnancy is less common in triple births, but may extend 
over hours and even days. The principal presentation is the cephalic — about 
60 per cent. The tendency to abnormal presentations is usually seen in the 
last child. The prognosis for the mother is less favorable than in single births. 
Notwithstanding what has been said of precipitate labors and short intervals, 
there are many protracted confinements which with the frequency of abnormal 
presentations contribute to the morbidity. Puerperal complications are fre- 
quent. The fetal mortality is very heavy, no less than 31 per cent, being 
still-born. 



XVII. MULTIPLE OR COMPOUND PRESENTATION. 

Owing to the small size of the fetus in multiple labors the element of dystocia, 
whether maternal or fetal, is essentially out of the question under ordinary 
conditions. Indeed, multiple pregnancy is an actual advantage to a woman 
with contracted pelvis. The situation is very different when the two children 
tend to engage in the pelvis at the same time, and especially when, by reason 
of the unusually small size of the heads, they succeed in so doing. Two types 
of complication thus arise, termed respectively (1) multiple presentation and 
(2) interlocking of fetal heads. These will be described separately. 

1. Multiple Presentation. — In multiple presentation we find parts from both 
fetuses at the pelvic inlet, and while engagement of both presenting parts 
may be possible, labor may be retarded by the fact that neither part is able 
to pass the brim. The presenting parts may be two heads, head and breech, 
head and limbs, or all the lower extremities (Figs. 703, 704, 705, 781, 782, 783). 
Treatment: In the case of two heads or a head and breech, the hand introduced 
into the vagina should endeavor to push one of the presenting parts, preferably 
that which is higher up, upward and out of the way. While this manipula- 
tion might suffice, some authors advocate engagement of the lower head with 
forceps to prevent a return of the complication. If a head and limb present 
together, the latter may be pushed up and the head engaged with the forceps. 
If the lower extremities descend into the pelvis, those which belong to the second 
fetus should be pushed up while the first fetus should be extracted by its feet. A 
complication of somewhat similar nature occurs when both bags of waters 
project into the dilating cervix and delay labor. It is necessary to wait 
until the os is fully opened, after which the most advanced bag should be 



614 PATHOLOGICAL LABOR. 

punctured. The question of multiple presentation has a medico-legal aspect, 
for the subject of the right of priority of birth sometimes arises. One fetus 
could present first by an extremity, for example, while the other might be 
born before it. 

2. Interlocking of Fetal Heads. — Interlocking of the fetal heads occurs in 
several ways, (i) When the heads are unusually small, a double cephalic pres- 
entation may result in the engagement of both, the second entering the pelvic 
cavity closely after the first, and becoming impacted against the neck or thorax 
of the first child (Fig. 707). Treatment: In the first form of interlocking the 
management usually advised is to deliver the first fetus with the forceps and 
then to extract the second. If the locking cannot be overcome, it may be necessary 
to perforate and dismember the first fetus, as otherwise both may be lost. The 
second child has the advantage over the first in that its cord is in less danger 
of compression. Some authorities appear to regard the prospect of unlocking 
these heads as practically hopeless, and proceed at once to perform craniotomy 
on the first fetus. (2) If the first twin has presented by the breech and has 
entered the pelvis with the exception of the head, the second head may slip past 
it into the excavation. If the fetuses are face to face, which is the usual rela- 
tion, the two chins may become locked together; if back to back, the occiputs; 
and if the back of one is to the face of the other, the locking occurs between the 
chin and occiput (Fig. 706). Treatment: The first step is an attempt to push 
the head of the second fetus up out of the pelvis. Failing in this, expectancy 
may be tried; but if there is no advance, the forceps should be applied. 
If delivery is still impossible, the head of the fetus which dies first (usually the 
first one) should be perforated and extracted in an attempt to save its fellow. 
(3) A second fetus in shoulder presentation may engage during the birth of the 
first fetus, so that the latter is arrested before some part of the trunk has entered 
the pelvis. Treatment: The engaged portion of the second fetus must be re- 
placed and traction made upon the other by the forceps or hands, according to 
the presenting part. If the first fetus is dead, it should be decapitated and 
an attempt made to extract the other by version. 

XVIII. EXCESSIVELY LONG CORD. 

The cord is frequently increased in length; instances being recorded in 
which it was from six to nine feet long. A long cord may become entangled 
in knots or it may become coiled about the fetus till so little is left that the 
symptoms of short funis are produced, causing delay in delivery. (See page 614.) 
It predisposes to prolapse of the funis. When the cord is coiled several times 
about the fetus, compression is liable to cause serious or fatal asphyxia. 

XIX. SHORT CORD. 

Definition. — Measurements of many thousands of umbilical cords show 
that the great majority have a length of from 17 to 24 inches (43.18 to 60.96 
cm.). An absolutely short cord is one which is too short to permit of delivery 
of the fetus before the separation of the placenta (Fig. 287). At the moment 
of expulsion the distance between the fundus uteri and the vulva is about 8 
inches (20.32 cm.). The cord must therefore be at least of that length 
to permit of the birth of a child. But the distance between the umbilicus 
and anus of the latter must be added if expulsion is to occur easily, so that the 
minimum normal length of the cord should be one foot (30.48 cm.) for head 



FETAL DYSTOCIA FROM GENERAL FETAL CONDITIONS. 615 

presentations, and by a like calculation 15 inches (38.1 cm.) in breech cases. 
An absolutely short cord must therefore be less than 15 inches (38.1 cm.)- This 
calculation was made by Tarnier and Leroy in 1893, who state that the ex- 
tensibility of the cord makes the above figures slightly too small (about 10 per 
cent.). The same effect of shortening may be produced in connection with 
coiling of the cord about the neck or limbs. This is termed the accidentally 
short cord, and is elsewhere considered. (Page 252.) 

Etiology. — The naturally short cord is purely an anomaly of development. 
It has been noted in successive labors in the same woman. In a portion of 
the cases reported the amniotic fluid has been scanty. 

Symptoms and Diagnosis. — There is no method by which a short cord re- 
veals itself during pregnancy, for even if the position of the child were affected, 
as has been claimed, no distinction could be made between natural and artifi- 
cial shortening. During labor, symptoms, while pronounced, are equivocal. 
With everything favorable for timely expulsion of the child, labor does not 
advance properly. The traction upon the cord during each pain is followed by 
a recoil of the presenting part, which is due to the elasticity of the funis. 
In individual cases the condition has been recognized by a combination of 
rational symptoms, such as tugging and unusual distress at the placental site. 
It doubtless happens that the conditions become manifest only when the 
placenta gives way with hemorrhage, or when the uterus becomes inverted. 
It would seem, at first sight, that after labor was well advanced the in- 
troduction of the hand might lead to a recognition of the condition, but 
practically nothing can be learned in this way. Little distinction is made 
in practice between a naturally and an artificially short cord. Brickner 
gives the symptomatology of short cord as follows*: (1) Recession of the head 
between pains; (2) arterial hemorrhage during and between pains; (3) urina- 
tion between pains during expulsive stage; (4) pain over the placental site, 
worse during the expulsive period; (5) desire to sit up and lean forward; 
(6) uterine inertia. 

Prognosis. — The mother is endangered by the possibility of hemorrhage 
and inversion of the uterus. A considerable proportion of infants are still- 
born. 

Treatment. — If there are reasons for suspecting the presence of a short 
cord, the membranes should be ruptured, manual expression begun, and the 
forceps applied. According to Budin, attempts to uncoil the cord or to perform 
podalic version are strictly contraindicated. If brevity of the cord is not 
suggested till the head is arrested in the excavation, there are no resources 
beyond the same combination of manual expression and forceps. The cord 
may rupture under traction, and in that case labor must be terminated rapidly 
and the funicular hemorrhage checked. After extraction of the head a coiling 
of the cord about the neck may be discovered. It is then better to cut and 
ligate the cord than to try to loosen the coils. The artificially short cord must 
not be confounded with the cord simply coiled about the neck or limbs, produc- 
ing no dystocia. Some of these coils maybe detached incidentally during in- 
ternal version. 



XX. RUPTURE OF THE UMBILICAL CORD. 

Rupture of the umbilical cord is an accident of rare occurrence. Etiology 
This accident may arise from shortness of the cord, which may be con- 
* "Am. Journ. Med. Sciences," Nov., 1899. 



616 PATHOLOGICAL LABOR. 

genital, or from the cord becoming wound about the fetus. It may also be 
due to abnormal insertion of the cord, or to precipitate labor. Prognosis : 
The child usually dies from shock or asphyxiation, or rarely from hemor- 
rhage; since the ruptured vessels are protected by the retraction of their tis- 
sues and by the covering of Wharton's jelly. Treatment : When this compli- 
cation takes place before the child's birth, either immediate version or the 
use of the forceps is indicated. 

XXI. DECAPITATION OF THE FETUS. 

This complication is also very rare, but sometimes occurs when too much 
force has been applied to the after-coming head, either in a normal breech 
presentation or after version. Treatment : The forceps or the craniotractor 
must be used to extract the fetal head, external pressure at the same time 
being employed to hold the latter in place. Danger of maternal laceration 
from bony spicules should be carefully avoided. (See Operations, Part X.) 

XXII. AVULSION OF THE FETAL EXTREMITIES. 

This can take place only when the fetus is premature or partially macerated. 
After its occurrence the rest of the body should at once be extracted. It will 
be well to follow extraction by an antiseptic douche. 

XXIII. FETAL MALFORMATIONS, DEFORMITIES, AND ANOMALIES 
PRODUCING DYSTOCIA. 

The malformations which give rise to dystocia are limited practically to the 
double monsters. Single fetuses with malformations do not, as a rule, produce 
obstructed labors, and are so few in number in comparison with the results 
of fetal disease that they are best considered under the same class as the latter. 
The best classification of double monsters as causes of dystocia is that pro- 
posed by Veit, and is as follows: 

i. Double Monsters with but a Slight Degree of Cleavage. — These comprise 
naturally all monsters joined by the head and trunk, by the pelvis and trunk, 
or by the greater portion of the trunk. In all these formations there is but a 
slight degree of separation either above or below or both. Following the classi- 
fication adopted in the present work (page 259), these groups belong to Veit's 
first class — somatopagi (Fig. 405), hemipagi (Fig. 416), and monosomi (Fig. 
412). The dystocic element in these monsters is found in their great circum- 
ference. Owing to the intimacy of union between the twins, anything like con- 
formation may at times prove impossible. If the monster is too large to be 
expelled spontaneously, an attempt should be made to extract it with the forceps 
or hand. Everything depends upon the presentation. If a monocephalus (Fig. 
422) presents by the head, there should not be an}^ dystocia; but if the breech 
presents, it will be necessary to bring down the monster's four legs to extract it. 

2. Double Monstrosities Which Have a Greater Degree of Separation than 
the Preceding. — Here belong those monsters which are separated at the poles 
only — the syncephali (Fig. 414) and sympygi (Fig. 400) of the classification in 
this work (page 259). These include the malformations commonly known as 
craniopagus (Fig. 413), ischiopagus (Fig. 403), and pygopagus (Fig. 404). 
None of them necessarily causes dystocia unless the presenting part is the 
seat of the fusion. If a craniopagus (Fig. 413) presents by the head, or one 



FETAL DYSTOCIA FROM GENERAL FETAL CONDITIONS. 617 

of the sympygi by the breech (Fig. 400), the position is of course dystocic. 
The pygopagus (Fig. 404) also has an extensive shoulder circumference, while 
the heads would be too large to pass the brim unless in succession. 

3. Double Monstrosities Which Have a Great Degree of Separation with 
More or Less Mobility of One Twin upon the Other. — Here belong the thora- 
copagi (Fig. 425) and monopygi (Fig. 406). These monsters are more fre- 
quently encountered than the two preceding divisions. Spontaneous delivery 
has often occurred. If any one of these monsters presents by the breech, its 




Fig. 784. 



Fig. 785. 



Fig. 786. 




Fig. 787. 



Fig. 788. 



Figs. 784 to 788. — Fetal Deformities Producing Dystocia. Fig. 784, Congenital 
hydrocephalus. Fig. 785, Anencephalus. Fig. 786, Distention of bladder and ureters. 
Fig. 787, Dicephalus dibrachius. Fig. 788, Thoracopagus. 



four legs must be drawn down. If it is too large for extraction, eventration must 
be practised. Otherwise an arm may be brought down either in front of the 
trunk or behind it. The heads can be brought down singly. The dystocic 
element appears in head presentations and is of a high degree, varying accord- 
ing to the mobility of one twin upon the other. If the separation is large, the 
second half of the monster readily falls into a transverse or oblique position. 
In such a case it should be turned at once. The head of the first half must 
then be delivered by the forceps, or decapitated if this is impossible. The second 
half must then be extracted with any necessary mutilation. If both heads 



618 PATHOLOGICAL LABOR. 

engage at the same time, one just behind the other, spontaneous expulsion 
is possible. If impaction occurs, the second head may be pushed up and an at- 
tempt made to deliver the entire monster by podalic version. The two heads 
could perhaps be delivered with the forceps with or without craniotomy.* 

The general principles which apply to the delivery of all monsters are as 
follows : (i) First to attempt to extract by podalic version; (2) if this cannot 
be done, to perform any mutilation necessar}^ to extraction; (3) Caesarean sec- 
tion is rarely, if ever, indicated in the absence of pelvic deformity. 

Oversize of the Fetus. — There is no standard of oversize, though infants 
weighing over 13 pounds (about 6000 gm.) at birth are very rarely encountered. 
A few cases of giant fetuses weighing 20 pounds (9000 gm.) and upward have 
been recorded. Excess of weight, however, does not necessarily involve a 
dystocic labor, for the head of such a child may have a good capacity for 
moulding. A representative case of an overdeveloped fetus causing dystocia is 
one described by A. Martin. t The child weighed over 16 pounds (7500 gm.), 
and could not be delivered until craniotomy had been performed. Dystocia 
from overdeveloped children is a very rare occurrence, as would naturally be 
the case considering the etiology. Etiology: Overdevelopment has but two 
known causes: (1) Heredity; the children of giants, especially the male chil- 
dren of a giant father, having a tendency to overdevelopment even in utero. 
(2) Prolongation of pregnancy. Post-mature fetuses naturally continue to in- 
crease in size until the deferred labor sets in. Symptoms and Diagnosis: A 
very large child in utero may simulate a twin pregnancy or other conditions 
of distention. Careful palpation and cephalometry (page 186) will show that 
there is but a single large child. Gestation with a very large fetus is accom- 
panied by the same phenomena as is multiple pregnancy. The distention is 
partly accounted for in the first case by the increased volume of the placenta 
and amniotic fluid. Labor with overlarge fetus is naturally slow and numer- 
ous accidents may arise. During dilatation the cervix may give way with a 
prolonged tear involving the body of the uterus. There is a similar danger 
of rupture of the lower part of the birth tract, especially the perineum. Diag- 
nosis must be made between a normal large head and hydrocephalus, short 
funis, and other causes of dystocia. Treatment: If labor cannot end spontane- 
ously without danger to mother and child, the indication is clear to apply the 
forceps. Version is not to be attempted. If the child succumbs during expul- 
sion, embryotomy should be performed. 

Oversize of the Head. — A perfectly normal fetus may have an abnormally 
large head, associated often with a tendency to premature ossification, with 
resulting diminution in the size of the fontanelles. These heads resist mould- 
ing, and this fact, in addition to their size, renders them apt to produce 
dystocia. Treatment: The indications are the same as in the preceding class; 
viz., expectancy at first, followed later by the forceps if necessary, or perfor- 
ation in the case of death of the child. 

Premature Ossification of Fetal Skull. — The symptoms, results, and treat- 
ment are the same as the preceding. 

Congenital Hydrocephalus. — Diagnosis: Abdominal palpation may dis- 
cover a large, hard, round tumor situated above the pubes, while the cardiac 
sounds will proceed from a point above the umbilicus. Naturally the abdo- 

* The great rarity of double monsters leads to the slighting of the subject in text- 
books, and the preceding account is given more as a complement to the classification and 
illustrations of monsters in the present work, than for any practical end (pages 259 to 285). 

f Cited by Tarnier and Budin, edition 1900, Paris. 



FETAL DYSTOCIA FROM GENERAL FETAL CONDITIONS. 619 

men is greatly distended. At the onset of labor in vertex cases dilatation 
proceeds very slowly, and the membranes are prone to premature rupture. If a 
vaginal examination is made at the time, the " feel of " the hydrocephalic head 
may lead to the belief that the membranes have not ruptured or that a second 
bag of waters is present. Failing to recognize the usual evidences of a head 
presentation, the practitioner may believe that a breech presentation exists. 
The diagnosis is made only by careful palpation of the various structures of 
the fetal head, for even after the recognition of a large, fluctuating mass it will 
still be necessary to exclude the presence of encephalocele and sacrococcygeal 
cysts. Examination with the entire hand is necessary for diagnosis. In 
breech presentations the presence of a large mass in the uterus during expulsion 
of the trunk might lead to belief in the presence of a second fetus, uterine 
fibroid, etc. The presence of spina bifida in breech cases has sometimes led to 
a suspicion of hydrocephalus. Prognosis: The outlook is grave. Very few 
labors terminate spontaneously. In cases in which an early diagnosis is not 
made the mortality is high. When the complication is foreseen, the outlook 
for the mother is good. The children mostly succumb to either primary or sec- 
ondary mortality. Survivors, of course, are doomed to hopeless idiocy. For 
the mother in undetected cases the outlook is bad, although it has been recently 
improved by superior antisepsis. The mortality to the mother averages about 
25 per cent. (Poulet and Spiegelberg). Rupture of the uterus is not uncommon, 
either near the cervix or at the fundus. Vesico-vaginal fistula may result from 
the pressure of the fetal head. In vertex presentations labor progresses very 
slowly, the head being unable to pass the brim; or if it engages it may readily 
be disengaged. The cervix dilates poorly and the tetanoid action of the uterus 
may provoke a rupture of the latter, for this accident occurs as often as once 
in five or six times in cases of hydrocephalic dystocia. If the nature of the 
complication is unsuspected, matters may be made worse by attempts at version 
or forceps delivery. In vertex cases labor can end only by spontaneous or 
artificial rupture or puncture of the diseased head. In breech cases labor is 
normal till the head reaches the pelvic brim, and after that the chances for 
expulsion are more favorable than in vertex. Treatment: The prophylaxis 
of hydrocephalus hardly exists, despite certain efforts in this direction. If 
the condition is recognized during the latter months of pregnancy, the fetus 
may be placed in a pelvic presentation, as there is less danger then of rupture 
of the uterus. When labor is much delayed by this complication, puncture of 
the head and withdrawal of the accumulated fluid are demanded. The cranial 
bones then collapse. If the aspirator is used, it will withdraw the fluid 
effectually, and give the child a chance of life. Even a short period of extra- 
uterine existence may sometimes be of great medico-legal importance. After 
perforation, turning has been advised, but this is usually superfluous, for the 
pains are generally sufficient to complete the birth. If there is difficulty in 
the descent of the head, application of the cephalotribe is in order. This will 
crush the head, so that it will be readily extracted. The forceps should not be 
used, for the blades are too short, and the cephalic curve is not large enough. 
The head, too, is so distended that its form changes with pressure to such a 
degree that the forceps cannot secure a firm grasp. It is only when the head is 
closely and deeply wedged in the pelvis, and its capsule is unyielding, that any 
success with the forceps may be hoped for. In breech cases the skull may be 
perforated from beneath. The French claim that the simplest manner of 
withdrawing the fluid is by puncturing the spine. This procedure, adopted by 
Tarnier in 1868, has been employed by all of his pupils. Cases of shoulder 



620 PATHOLOGICAL LABOR. 

presentation should be treated by preliminary podalic version and afterward 
as in the management of breech cases. If version is contraindicated, decapita- 
tion should be practised. 

Encephalocele ; Hydrencephalocele (Figs. 337, 338). — As a monstrosity this is 
discussed on page 275. This condition is rarely a cause of dystocia. The 
tumor which projects from the skull consists only of fluid in a membranous 
sac. If large enough to obstruct labor, it could readily be tapped. Epignathi 
(Fig. 438): These parasitic tumors, growing as they do from the mouth, are 
able to, if they are large, cause more or less dystocia. They are freely movable 
on the fetus and extraction can usually be effected by version. If this fails, the 
epignathus must be reduced in size. Anencephalus (Fig. 375): In this mon- 
strosity dystocia arises from the fact that the rudimentary skull is insufficient 
to pave the way for the shoulders. The condition is therefore one of shoulder 
dystocia, for which see page 590. Cystic Hygroma: These cystic formations 
grow from the neck or the front of the chest, and may equal the fetal head 
in size. They are retention cysts which arise after occlusion of the lymph- 
atics. Congenital Cystic Goitre : This may be classed with the foregoing in 
relation to dystocia. Winckel gives considerable attention to these cysts 
of the neck, as do also Tarnier and Budin. The cysts are not diagnosticated 
until labor has begun, and then are made out only with several fingers in the 
vagina, and sometimes not until after delivery. If moderate traction will not 
bring away the child, the tumor should be punctured with a curved trocar. 
The greatest care should be taken, since these cysts do not jeopardize the 
child. 

Unusual Width of the Shoulders and Chest. — The shoulders and thorax of 
a very large child do not appear to cause dystocia. Unusual development 
of these parts in an ordinary child, as well as the absolute and relative width 
of the shoulders in pseudo-encephali and anencephali, constitutes the state 
which produces dystocia. Similar in dystocic effect is congenital hydrothorax. 
Labor in such cases might be arrested with the shoulders in the inlet, and the 
efforts of the uterus to expel the child might asphyxiate it as a result of com- 
pression of the chest. Diagnosis: These ' conditions cannot be recognized 
till after the birth of the head or the breech, when, with the entire hand 
in the vagina, the diagnosis may be made. Treatment: This should not be 
confounded with the management of deficient rotation of the shoulders. To 
overcome the impaction present in actual dystocia it will probably be neces- 
sary to perform cleidotomy. (See Operation, Part X.) 

Ascites. — (See Trunk Dystocia.) (Fig. 786.) 

Tumors which Originate in the Urinary Apparatus. — These comprise ac- 
cumulations of fluid in the bladder or kidneys due to imperforate urethra 
or some other malformation, and also the condition known as congenital cystic 
degeneration of the kidney. Both distended bladder and hydronephrosis 
may attain an enormous size in comparison with the fetus (Fig. 786). While 
the average quantity of urine which thus accumulates is not over a pint, 
there are cases upon record in which the retention amounted to seven quarts. 
The kidneys in cystic degeneration form a large, solid tumor which is made 
up of innumerable retention cysts developed from the urinary canaliculi. 
These cysts are filled with urine, and when the process is extensive a large 
abdominal tumor results. It is supposed that the retention is due originally 
to a sclerotic process in the renal papillae. An analogous affection of the liver 
sometimes coexists. 

Dystocia Due to Affections of the Fetal Trunk. — Symptoms: During labor in 



FETAL DYSTOCIA FROM GENERAL FETAL CONDITIONS. 621 

cephalic presentations after the head is born, the process of delivery is arrested. 
If an inexperienced practitioner attempts to extract the child forcibly, he will 
be likely to disrupt it. If the case is a breech, the conditions are analogous. 
A fetus with retention of urine almost always presents by the head. Naturally 
there is a scantiness of the amniotic fluid. Diagnosis: If there is obstruction 
due to something above the shoulders, the entire hand should be inserted into 
the birth tract, when the nature of the obstacle will become apparent. An 
attempt should be made to determine whether the tumor is solid or fluid. An 
analogous course should be pursued in breech cases. Prognosis: The outlook 
is naturally grave for the fetus that is already the victim of disease or malfor- 
mation. For the mother, all depends upon the management of the case. If 
the cause of dystocia is not recognized and removed, she will be exposed to 
extensive rupture of the genital tract by the futile attempt at delivery. If the 
correct diagnosis is made, the mother's chances are vastly improved. Treat- 
ment: In head presentations with the head arrested in the excavation, the for- 
ceps should be applied to deliver it. Any coils of cord about the fetal neck 
should be unwound. Traction should be resumed gently until no further 
advance is possible, after which the hand in the vagina will complete the diag- 
nosis as to the nature of the tumor. If the latter contains fluid and the infant 
is dead, the abdomen should be opened by a perforator. Labor may then 
be readily completed. If the child is living, puncture should be made at the 
umbilicus with a fine trocar. If the tumor is solid, the child must be eviscer- 
ated whether dead or alive. In breech cases an analogous course must be 
pursued. It must be remembered that the placenta is very large in some cases 
of ascites; if this is forgotten, the uterine tumor might suggest a second fetus. 
Sacro-coccygeal Tumors. — These growths are described on page 284. (Figs. 
440 and 445.) They are seldom recognized during pregnancy. Hydramnios is 
present in the vast majority of cases. Symptoms : Labor is almost always 
premature. The head usually presents. Delivery occurs spontaneously in the 
vast majority of cases. This implies that the majority of tumors are too small to 
affect labor. More or less dystocia must occur with growths the size of the fetal 
head. The degree of dystocia is not in proportion to the size of the tumor, for 
the latter may be partially cystic, and hence easily reducible in size. In head 
presentations with a large solid tumor the latter will probably be expelled spon- 
taneously after a period of moulding. In pelvic presentations a high degree 
of dystocia may result, the trunk and tumor seeking to engage at the same 
time. If the feet are down, efforts at traction might disrupt the fetus. Diag- 
nosis: This can be made only with the entire hand in the vagina, chloroform 
having been given. A tumor of this sort might well be confounded withTa 
number of conditions, fetal or maternal. Budin states that the commonest 
error is the assumption of the presence of a double monster united at the breech. 
Prognosis: In dystocia the maternal prognosis depends, as in all similar con- 
ditions, upon the time at which the diagnosis is made. The outlook for the 
child is very poor, there being but a small proportion of survivors. Treat- 
ment: The dystocia is less than in the case of abdominal tumors. In head 
presentations traction should be made with forceps until it becomes evident 
that delivery is impossible. Puncture should be practised in several places in 
the hope that the tumor is partly fluid. If this fail, the child must be even- 
trated, after which the legs may be extracted and the tumor treated by morcel- 
lation, while in a breech case the tumor must be made to present first with the 
same intent. 



622 PATHOLOGICAL LABOR. 



XXIV. FETAL RIGOR MORTIS. 

Although death of the fetus is of such common occurrence, rigor mortis 
has been noted so rarely that the possibility of such a phenomenon has been 
denied. Ballantyne, who has seen one case, gives references to about twenty- 
five others in literature, several of the latter having been described in connec- 
tion with Csesarean section. Cadaveric rigidity in the fetus is believed to be 
feeble and transitory, and to escape observation unless death occurs just before 
labor begins. In some cases, however, the condition is well marked, and may 
last for hours, proving a source of fetal dystocia. Wolff * analyzed 34 recorded 
cases of this phenomenon. The claim which has often been made that eclamp- 
sia plays a prominent part in its genesis is not borne out by statistics, for maternal 
convulsions occurred in but 8 of these 34 cases. This coincidence is evidently 
due to the fact that the fetus often perishes during an eclamptic delivery. For 
similar reasons we find the coincidence of protracted and obstructed labor, 
prolapsed cord, placenta praevia, premature detached placenta, etc., on one hand, 
an antenatal rigor mortis on the other. 

Of the 34 cases detailed by Wolff, no less than 30 were associated with the 
conditions just enumerated. 

These, however, were not sufficient in themselves to determine rigor mortis 
in the fetus. In a large proportion of cases, the latter may be brought in re- 
lation with death of the mother during labor, and it is not uncommon for the 
rigid state of the fetus to be recognized in connection with Caesarean section on 
the dead or dying. 



DUE TO ABNORMAL CONDITIONS IN THE MOTHER. 
MATERNAL DYSTOCIA. 

Physical Phenomena of Maternal Dystocia. — Much confusion exists in regard 
to the results of difficult labor upon the maternal organism, and the terms " prim- 
ary inertia," "uterine exhaustion," "secondary inertia," " tetanoid state of the 
uterus," "delayed labor," "obstructed labor," are applied somewhat indis- 
criminately to designate various phases of such conditions. An attempt is made 
to submit these conditions to a brief analysis. 

Primary Inertia. — Here the sluggish action of the uterus is not due to ex- 
haustion. The causes lie in the uterine muscle itself, which is unable to contract 
forcibly. We see this in the very young and in the elderly; in invalids and in 
distention of the uterus by hydramnios, multiple pregnancy, etc. The pains 
are weak and occur at long intervals. There is no constitutional reaction beyond 
fatigue. The subject of inertia is considered in detail under Protracted Labor. 

Secondary Inertia, Exhaustion of the Uterus. — This appears to be the result 
of inertia of the uterus plus slight obstruction ; although the latter is not always 
in evidence. The pains, feeble at the start, ultimately cease. The uterus seeks 
rest. This temporary suspension of the pains has been termed secondary inertia 
in contradistinction to obstructed labor with original absence of inertia. Exhaus- 
tion of the uterus betrays itself by flabbiness, which enables the obstetrician 
to recognize the outlines of the child. There is no tenderness on pressure. 

* " Arch. f. Gynakol.," lxviii, 1903. 



MATERNAL DYSTOCIA FROM THE FORCES. 623 

Aside from fatigue, constitutional reaction is absent. After rest, food, and sleep 
the uterine contractions reappear. 

Tetanoid State of the Uterus. — This anomalous action of the uterine muscle 
develops when an obstruction is present. The original pains become vigorous 
when the obstruction is first felt, but if the impediment cannot be overcome, the 
intervals between the pains become shorter and shorter until the tetanoid state 
develops. The fetus is closely embraced by the uterus and the constant pressure 
tends to interfere with the placental circulation. The constitutional reaction 
is marked, as the tetanic contraction rapidly exhausts the mother. Her pulse 
and respiration increase and her face shows anxiety. The uterus is hard and 
perhaps tender. It holds the fetus firmly, so that the presenting part cannot 
be pushed up. If the head has reached the true pelvis, it shows a marked caput 
succedaneum, while the lower part of the birth tract is swollen. In this condi- 
tion immediate delivery is the indication. 

Prolonged Labor. — This term is somewhat vague. Primary inertia, exhaus- 
tion, and obstruction all tend to lengthen the duration of labor. What is meant 
by prolonged labor in the narrower sense of the term is the result of a moderate 
disproportion between the force and the resistance. Let us suppose that the 
pains are strong and that the resistance does not amount to obstruction. 
Tetanus uteri does not develop. The woman is simply in the position of one 
who makes great and long-continued muscular exertion, and the results are 
those which follow such efforts. The pulse rises to ioo or 120 and there is rise 
of temperature. The patient becomes anxious, distressed, and restless; vomit- 
ing of reflex origin may occur; the tongue is coated, the vaginal and cervical 
secretions are arrested, and the parts are hot and dry. Such a clinical picture 
may be seen in breech presentations. 

Obstructed Labor. — This term is also somewhat ambiguous. Tetanoid con- 
tractions indicate that there is an obstruction to labor. There is only a mere 
difference in degree between a protracted labor as described and an obstructed 
labor. The term should be restricted to cases in which delivery by natural 
passages is impossible. At the outset the symptoms are those of protracted 
labor. Finally exhaustion of the mother begins ; the pulse becomes weak and 
thready ; jactitation indicates the high degree of nervous prostration ; the tongue 
becomes black and dry, and the patient passes into a typhoid or adynamic state 
as a result of the profound exhaustion. 



MATERNAL DYSTOCIA FROM THE FORCES. 

I. PRECIPITATE LABOR. 

Definition. — Labor terminating so rapidly as to interfere with the physio- 
logical processes of the several stages. Its occurrence is comparatively infre- 
quent. A narrower definition is labor of such rapid and unforeseen character 
that the parturient is confined in an entirely unusual position, as standing, 
squatting, kneeling, or sitting. 

Etiology. — Excessive expulsive powers, either voluntary or involuntary, and 
deficiency in the resistance in the parturient canal or bony pelvis are the main 
etiological features. The physical condition of the patient seems to have 
little or nothing to do with the excessive contraction. Deficiency in the resist- 
ance may result from a number of causes. For example, there may be an under- 



624 PATHOLOGICAL LABOR. 

sized child at full term or as the result of premature labor. The parturient 
canal itself may be oversized and roomy and relaxed as the result of the general 
physical condition or nervous influences independent of an increase in the size 
of the pelvis. The justo-major or giant pelvis and the split or inverted pelvis 
are the two conditions in the hard parts predisposing to precipitate labor. It 
may be that in a previous confinement there have been lacerations of the cervix 
or perineum, or both, allowing the fetus to be precipitated through an orifice, 
instead of being forced along, as is normally the case. 

Symptoms. — The symptoms are those of a rapidly terminating labor. The 
pains appear suddenly and increase very rapidly in intensity. They are usually 
of a bearing-down character from the beginning. Labor may be over in a few 
minutes when the pelvis is large or the fetus small, even without any excruciating 
pains. However, the converse may prove true. The child may even be born 
while the mother is asleep. 

Diagnosis. — One or two contractions sometimes expel the fetus. In other 
cases palpation shows a rapidly advancing presenting part, almost continuous 
tetanic action of the uterus, and forcible contraction of the abdominal walls. 
The latter may be absent. In cases in which there are only one or two severe con- 
tractions the patient is probably of a sluggish, apathetic temperament and does 
not really feel much pain. In other cases which are not so rapid the suffering may 
be intense. If the child dies from rupture of the cord as a result of precipitate 
labor, the mother may be subjected to judicial inquiry by reason of the fact 
that infanticide is sometimes committed through neglect to ligate the cord. 
Similarly, a fall of the child in connection with precipitate labor may lead to 
injuries of the cranium, limbs, viscera, etc., and hence the suspicion of attempt 
at infanticide may be aroused. In cases of this sort in which the mother is 
accused but denies all intent of injuring the child, corroboration of her word may 
be supplied by study of the pelvis and soft parts and of the fetus. If the pelvis 
is over-large and there are old lacerations which have diminished the resistance, 
etc., or if the child is unusually small, we have conditions which favor precipi- 
tate labor. If we find the uterus inverted, extensive fresh lacerations of the 
soft parts, with a history of post-partum hemorrhage, etc., we have conditions 
which may have been caused by precipitate labor. In regard to the child dead 
of hemorrhage from the cord, it will be necessary to exclude the existence of 
patent umbilical arteries, anomalies of the cord and vessels, and hemophilia. 
Much may be learned from cross-examination of the mother. 

Prognosis. — The dangers to the mother are hemorrhage from premature de- 
tachment of the placenta, lacerations of the parturient tract, post-partum hem- 
orrhage, inversion of the uterus, serious or fatal syncope from sudden diminution 
of intra-abdominal pressure, and uterine inertia. The dangers to the fetus are 
ante-partum asphyxia from premature detachment or compression of the placenta 
or from rupture of the cord, and injury from a fall to the floor, to the street, or 
into the basin of a water-closet. I had a case in practice of a child being born 
by precipitate labor into the bowl of a water-closet. I was asked once to see 
a depression in a parietal bone in a newly born infant, the result of precipitate 
labor on the fire-escape of a tenement-house. The mother at the time was 
leaning over the railing and drawing the clothes-line toward her. Both these 
children survived. I have also witnessed a precipitate labor in a patient ascend- 
ing a staircase in a maternity hospital, the child's fall in this case being 
broken by being suspended by the cord. No complications resulted to the 
mothers in these three cases. 

Treatment. — When precipitate labor has once occurred, it is likely to take 



MATERNAL DYSTOCIA FROM THE FORCES. 625 

place again, and so preventive treatment is in order during pregnancy in such 
a case. During the last few weeks of pregnancy the patient should not go far 
from home and should secure fresh air by driving rather than walking. A com- 
petent nurse, who can take entire charge of labor if necessary, should during this 
time be in attendance. A well-fitting abdominal binder (Fig. 233) will some- 
times act as a preventive measure. All mental reflex irritation must be guarded 
against. Repeated small doses of the bromids or of opium are of use to quiet 
the irritable state of the uterine muscle-fibers, as in the case of treatment of 
abortion. During labor the early use of chloroform or the subcutaneous use of 
morphin is most valuable, and all bearing-down efforts on the part of the patient 
must be discouraged. She should be placed in the lateral posture or, better 
still, in the exaggerated semi-prone (see Posture, Part X), and manual retarda- 
tion of the head at the pelvic outlet practised if necessary. 

II. PROTRACTED LABOR. UTERINE INERTIA. 

Definition. — Labor prolonged beyond the average length (page 499) to such 
an extent as to be dangerous to mother or fetus ; or a degree of uterine contrac- 
tion insufficient to overcome the normal resistance or that produced by some 
abnormality. Uterine inertia is that condition in which the uterine contractions 
by reason of their weakness or irregularity are insufficient to dilate the os in the 
first stage, or expel the fetus in the second. The insufficiency may pertain only 
to a certain portion of the uterus; so that we may speak of partial and total 
inertia. Thus the defective action may be confined to the cervix. Abdominal 
inertia is a weak or inefficient condition of the abdominal walls which renders 
the patient unable to aid the uterine contractions of the second stage by her 
voluntary forces or bearing-down efforts. Three degrees of abdominal inertia 
are recognized; namely, simple inertia, exhaustion, and paresis. From the date 
of the beginning of uterine inertia, whether from the onset of labor or after a 
period of normal pains, a division is made of primary and secondary. Primary 
or true uterine inertia is that condition of weak pains in which the uterine con- 
tractions have been inefficient from the beginning of labor. It is an unusual 
variety of prolonged labor. Neither mother nor fetus need necessarily suffer. 
Secondary inertia or uterine exhaustion is a gradual or sudden cessation of strong 
uterine contraction, generally in the second stage. Contractions may subse- 
quently recommence spontaneously. 

Etiology. — The causes of primary inertia do not coincide with those of the 
secondary type. The former might arise from a great variety of conditions, as 
follows : • (1) Defective innervation (paralysis of the nerve-centers which preside 
over uterine contractions); (2) defective development of the uterine muscle; 
(3) abnormal shape of the uterus, as in uterus bicornis; (4) abnormal position 
of the uterus, as in the anteversion which accompanies a pendulous abdomen, 
and in prolapse; (5) abnormal distention of the uterus, as in hydramnios or 
twins; (6) diseases and tumors of the uterine wall; (7) too intimate adhesions 
between the embryonal sac and the cavum uteri. Numerous contributory 
factors are also known to exist. Uterine inertia is thought to be hered- 
itary. It is common in elderly primiparae and in multiparas who have gone 
many years without becoming pregnant. On the other hand, we see inertia 
frequently in the opposite condition of too frequent labors. As a rule, we find 
weak pains in the obese, in delicate women, in invalids, in convalescents from 
acute infectious diseases, and in those who are poorly nourished from any cause, 
especially in victims of hyperemesis gravidarum. Remediable factors are found 
40 



626 PATHOLOGICAL LABOR. 

in distended bladder and rectum, tympanites, and overloaded stomach; all of 
which have been known to impede the healthy action of the uterus. Secondary 
inertia occurs more frequently than primary. It is common in primiparae 
whose soft parts are rigid, and, generally speaking, it is found in any condition, 
whether maternal or fetal in nature, which heightens the resistance to the normal 
passage of the child. The conditions which make up the etiology of the 
obstructive inertia need not be detailed in this connection. Partial inertia is 
due usually to the presence of some local lesion or tumor of the uterus. Abdom- 
inal inertia occurs in the presence of grave diseases, such as typhoid fever or 
tuberculosis; in inanition from any cause, and as a result of the inhibitory in- 
fluence of pain and profound mental emotion. 

It is readily apparent that primary and secondary inertia are not closely 
related, the latter being due to obstructive conditions which at times must 
exhaust the most vigorous uterus. For this reason primary inertia is some- 
times spoken of as true or essential inertia, while the secondary form is char- 
acterized rather as an exhaustion or paresis. Still the two forms do possess 
some features in common. Thus, vigorous contractions often readily overcome 
slight degrees of obstruction which could determine secondary inertia in a slug- 
gish uterus. 

Symptoms. — In the First Stage. — One of the first symptoms is the failure of 
the uterine contractions to cause progressive dilatation of the cervix. Soon the 
contractions become of short duration with longer intervals; they are accom- 
panied by excessive suffering, giving rise to the expression "painful pains"; 
they become cramp-like and irregular, and finally during each painful contraction 
no thinning of the cervical lip or protrusion of the bag of membranes occurs. 
Examination of a primipara will usually reveal a firm cervical ring and no ap- 
parent obstacle to the completion of the first stage, provided only strong uterine 
contractions were present. In the case of a multipara the contractions present 
will usually be less painful, with long intervals, and a soft, flabby cervical ring 
will usually be found, with vaginal walls so soft and readily dilatable that it 
appears that only a few contractions accompanied by some abdominal efforts 
would suffice to expel the fetus. In either case at this period the patient may 
fall asleep and efficient contractions may not recur for twelve or twenty-four 
hours. For a long period there are, as a rule, no symptoms beyond the mere 
delay of labor. If the membranes are intact, this stage may persist for several 
days without serious effects upon mother or child. Some fatigue and loss of sleep 
necessarily result. If, however, the difficulty is found to be due to some condition 
of the cervix, such as rigid os, exhaustion will ultimately be substituted for 
simple inertia. (Exhaustion is considered under the head of the second stage of 
labor.) In case of premature rupture of the membranes the symptoms become 
more serious, though less so than in the second stage. The liquor amnii escapes 
slowly and the futile efforts to open the cervix will lead to exhaustion at a much 
earlier period than will inertia with bag of waters intact. A tetanoid contraction 
of the uterus may be present during the first and second stages of labor, but this is 
not the rule, as the contractions may be simply weak, irregular, or painful in 
type. Should partial or complete escape of the liquor amnii ensue, a dangerous 
complication results ; for even should the head for a time act as a ball-valve and 
keep back some of the water, "dry labor" is always to be feared, with its tendency 
to retraction of the uterus, ascent of the contraction ring, dangerous thinning of 
the lower uterine segment, and disturbance of the utero-placental circulation. 
What contractions now remain tend not to cause dilatation and expulsion but 
a further thinning of the lower uterine segment and finally its rupture. 



MATERNAL DYSTOCIA FROM THE FORCES. 627 

In the Second Stage. — In simple protraction of the second stage of labor the 
symptoms at the outset are not unlike those of the first stage. The uterine 
contractions may be weak and irregular or tetanoid — usually the latter. Inves- 
tigation may show that the auxiliary forces are not co-operating with the uterus. 
There may be no bearing-down, especially in cases in which for any reason the 
patient is unable to fix her diaphragm (cardiac or pulmonary disease) ; or when 
the abdominal wall is the seat of any structural or functional disease (oedema, 
corpulence) ; or when fear exerts an inhibitory effect upon labor. The extreme 
pain may cause the woman to cry out unceasingly, so that bearing-down is im- 
possible. Finally, inertia may depend upon some simple local condition (an 
unemptied bladder or rectum), or upon some psychical cause easily remedied, 
as the presence of an obnoxious individual. If inertia persists during the second 
stage, the most important symptoms may have reference to the child, who will 
be almost certain to become asphyxiated. The pressure of the fetal head upon 
the soft parts, which will cause sloughing if continued, does not betray itself by 
any special train of symptoms. A general characteristic of inertia in the second 
stage is the dry condition of the maternal passages from the failure of the natural 
secretions of the cervix and vagina. 

Exhaustion. — This should be separately considered, for while primary inertia 
may end in exhaustion if the patient is not relieved, this abortive ending of labor 
is more commonly a result of obstruction to the passage of the child in the pres- 
ence of contractions of the uterus originally normal. It is especially in these 
obstructive labors that a peculiar condition of the uterus is prone to develop 
which is known as "continuous action." This, however, is not confined to ob- 
structive cases, but may be seen in simple inertia even in the first stage of labor. 
The continuous or tetanoid action of the uterus is brought about as follows: The 
abortive contractions, if regular, succeed each other with progressively diminish- 
ing intervals until they finally merge into a state of tonic contraction. Experi- 
ence shows that in simple inertia the tetanoid state supervenes rapidly; while in 
obstructive conditions with strong pains it is deferred. It is important to dis- 
tinguish between this tetanoid state and simple passivity of the uterus, as there 
is no doubt that they have been and still are confounded. Practically the tetanoid 
uterus is an affair of the second stage of labor, though exceptions may occur. 
This distinction is highly important in practice, as oxytocics are absolutely con- 
traindicated in the tetanoid uterus. The symptoms of the latter are revealed by 
abdominal palpation, the permanent rigidity of the womb contrasting strongly 
with the soft, lax structures felt when the uterus is merely relaxed. Another 
result of the abortive labor pains is retraction o) the uterus in obstructive 
cases, which is brought about as follows: The strong contractions of the 
uterus ultimately determine a stretching of the lower segment, which gives 
way under the pressure of the fetus. As the cervix stretches the body undergoes 
a corresponding thickening, and the retraction ring or Bandl's ring shifts its 
position upward. This ring sometimes becomes recognizable by external palpa- 
tion, and is then regarded as indicating intervention, but not version. Retrac- 
tion of the upper segment as just described is said to occur most commonly after 
early rupture of the membranes. Inertia, either primary or secondary, should 
not be confounded with non-advance of labor from undue obliquity of the uterine 
axis. The phenomena of exhaustion, when the latter is once established, do not 
differ from those of adynamia in general. 

Diagnosis. — Statements of the woman to the effect that the pains are weak 
have little value. Diagnosis is readily made, as a rule, by palpation, which 
reveals the absence of a natural uterine action, and by the arrest of labor. If 



628 PATHOLOGICAL LABOR. 

the presenting part advances slightly, it is only to recede again. Upon timing 
the pains they are found to be very short, with long intermissions. The fetus 
exerts active movements during the interval. The diagnostic features of tetanoid 
uterus have been enumerated. 

Prognosis. — In primary inertia the prognosis for the time being is good if the 
bag of waters does not rupture. Before rupture of the membranes the first stage 
of labor may be much prolonged, even several days, without serious result to 
mother or child, although this favorable ending cannot always be looked for. Ner- 
vous exhaustion which follows the suffering, anxiety, loss of sleep, insufficient 
food, etc., must always be guarded against, for extreme exhaustion predisposes to 
subsequent accidents in labor and the puerperium. If the waters break before the 
dilatation of the cervix, an additional cause of inertia is supplied. The chief 
danger to the fetus is found in the prolonged compression of the skull and pla- 
centa, which favors the development of asphyxia. The mother is threatened with 
the formation of a passive oedema of the parts in advance of the fetus, which in 
turn predisposes to necrosis and the eventual development of fistulas, to say 
nothing of the added dangers of infection. It must not be forgotten that inertia 
has been known to terminate in precipitate delivery. This can hardly be due to 
sudden return of uterine vigor, but to the fact that labor has progressed more 
rapidly than the physician supposed. Excessive delay in the second stage is 
always dangerous for both fetus and mother: for the former because of asphyxia 
from compression of the head and placenta; for the latter from exhaustion, 
pressure necrosis and fistulas, rupture of the uterus, septic conditions, and 
post-partum hemorrhage from uterine atony. 

Treatment in the First Stage. — In the great majority of cases of delayed labor 
in the first stage there is no real obstruction in the cervix. The latter will almost 
always dilate readily enough if the expulsive powers are sufficiently strong. The 
first principle of treatment is to ascertain the cause of inertia and to remove it. 
This may be a distended bladder or rectum, or the excessive pains of uterine 
contraction, especially when spasmodic in character. As the invariable indica- 
tion is to accelerate the first stage of labor, any legitimate means at our disposal 
may prove of service, and our resources may be divided into two groups: (i) 
Those applied outside the parturient canal, and (2) those which we make use 
of within the passages. As a general principle, we should avoid recourse to the 
second group as far as possible. 

(1) Means jor Accelerating the First Stage of Labor, which are Applied without 
the Passages. — All our resources should be set in operation, even those of the 
simplest character. Rest, a short sleep, feeding, and stimulation are all of benefit. 
Exercise in the form of walking is often of value. It not only strengthens 
feeble contractions, but when the latter have ceased for a time, — which often 
happens after early rupture of the membranes, — it brings about their reappear- 
ance, doubtless through reflex excitation by the weight of the presenting part 
on the lower uterine segment. Other postural resources, such as the squatting 
position, cannot be recommended because of the danger of prolapse of the cord. 
The physician must not overlook the possibility that the cause of inertia may 
be found in a distended bladder or rectum, and must guard against such a 
contingency. Heat is a valuable stimulant to the sluggish uterus, and may 
be administered in the form of a general shower or douche bath (Fig. 621) 
or hot compresses applied over the sacrum and hypogastrium. In the 
latter form the action of the heat is reinforced by alternation with cold. A 
large number of oxytocic drugs have been used, some for stimulant, others for 
sedative action. Ergot should never be used in the first stage of labor; it 






MATERNAL DYSTOCIA FROM THE FORCES. 629 

should be given only after the expulsion of the placenta. Quinine is 
largely used at the present day, and acts prQbably as a purely nervous 
stimulant. When the stomach is irritable, I employ large doses of the 
bisulphate of quinine (grs. xx to xxx) in rectal suppositories. A group 
of sedative drugs comprises chloral, tincture of gelsemium, and the coal-tar 
products. These are indicated in irregular and painful contractions. The 
two latter drugs possess no advantage over the former, which is now in 
almost general use. Opium appears to act as a sedative in irritable conditions 
and as a stimulant in sluggishness. General anesthesia is contraindicated during 
the first stage of labor, but the inhalation of a few drops of ether or chloroform 
is often employed for sedative effect in irregular and painful contractions. If 
too much chloroform is inhaled, the action is too pronounced and the contrac- 
tions may be arrested entirely. On this account, if anesthetics are employed 
at all, ether or the A. C. E. mixture should be preferred. In instances in which 
the severe pain and cramp-like action of the contractions appear to interfere 
with the progress of cervical dilatation, I have found that pouring a small quan- 
tity of ether into an Allis inhaler, and allowing the patient to inhale it, controls 
the suffering quite as well as does chloroform, and there is much less danger of 
producing inertia uteri. Cocaine applied directly to the cervix has been used 
as a local anesthetic, as has spinal analgesia. (See Part X.) Manual friction 
of the fundus uteri, manual expression (Part X), and the like are hardly indicated 
in inertia of the first stage unless dilatation of the cervix is over half completed. 
Voluntary efforts at bearing-down are likewise of little service, save when the 
cervix is partly dilated, especially in multiparae, and when rupture of the mem- 
branes has occurred. I have abandoned the use of electricity as dangerous to 
the fetus in the first stage of labor. A resource which forms a class by itself, 
since it is applicable during pregnancy rather than in the midst of labor, is the 
continuous use of strychnine for some weeks before delivery. This is more than 
a mere oxytocic, for it is also a prophylactic against a flabby uterus after delivery. 
Its special field appears to be in debilitated women. It should be given at first 
in doses of -^ grain three times daily, beginning at not less than four or more 
than eight weeks before the expected confinement. One week before the date 
of the latter the dose may be increased to -fa or even yg- grain. I have 
used the drug in this manner in many multiparas with a history of feeble, irreg- 
ular, and faulty uterine contractions, post-partum hemorrhage, or severe after- 
pains, and with most excellent results. Strychnine is also of use during the first 
stage of labor as an oxytocic, but then should be given hypodermatically. The 
amount given is -fa grain every fifteen minutes until T V grain has been taken. 

(2) Means for Shortening the First Stage of Labor that are Used within the 
Passages. — It may be that the uterus responds to the various stimuli but the 
woman has become exhausted from the delay, so that more radical intervention 
is called for. We must have made sure that there is no mechanical defect; 
this necessitates a careful internal exploration. The simplest internal resource 
is the hot vaginal douche, especially indicated in cases in which the lower uterine 
segment has been forced downward into the pelvis with resulting incarceration 
between the fetal head and the bony pelvis, causing oedema of the os. If the 
cervix is partially open and contractions are present which do not cause any pro- 
trusion of the bag of waters, we may suspect the presence of adhesions between 
the membranes and the uterine wall. This condition is remedied by the finger 
introduced into the cervix to the extent of two joints, and swept around 
within the ring of the os. In primiparas this is difficult of execution, and it 
may first be necessary to push the fundus downward and backward. Care must 



630 



PATHOLOGICAL LABOR. 



be taken, while detaching these adhesions fcc :>id rapturing the membranes, 

--him is : : 5 : likely t : harp en i: the rrrer is use! rather thar a :atheter ~ith sty- 
lei I: These measures ,i:t -jr.su: lessful inrauTerlne immtim ir s:ne fern trust 
be employed. Bougies introduced between the membranes and the uterine 
Trail and =ll:~ei t: terrain : : : ::. are attended :y sl:~ and ur: errant results. 
A resource attended by a prompt response is the principle which underlies 
the bags of Barnes and Champetier de Ribes; these devices not only excite 
uterine contractions, but dilate the cervix as well (see Part X). As far as 
the simple indication of accelerating labor is concerned, it need only be said 
that the prlrriple :: These hydrauli: dilate rs may usually "re iisTersei -vith 
art :ert airly should : e ~her p : ssihle 5 :r:e lea dmg autocrines regard manual 
dilatation of the cervix for simple inertia as nothing less than malpractice. 
Hc~ever er gentle dilatation intended simply to stimulate the uterus 
is a raritral procedure and nay safely ': e lire ~:t1: The rlrgers See 
Manual Dilatation of the Cervix, Part X.) It is especially applicable when 
the :s is partly dilated s::t and pushed 1:~ do— - utt: The pelvis lr:isi:rs 
are as utile indurated as is imrrmaertal draiaTirr 1: an emergen: - .- arses so 
that the indication is to extract the child at once, one or both of these last- 
rremicred prmedures may re reiuired 

In the Second Stage. — After :er nal dilatatizr The treatment of delayed 
later usually 'reoimes a simple maTTer ir the a':se:t:e :: maternal :r fetal :':- 
strmnm and res: Ives itself usually intc the applisation of the f:r:eps. —her 
the positive irditatior she— s itself either :r the mart :: the fetus :r :r that 
:: the mother Pam X l::as::rahy ir mmengagemem :: the head the 
:h:i:e —hi :e zetvreen fcrteps ardversior. Pam X Stmrhmre :'rl:ti:r r: 
:cmpressi:r ::' the fundus emouragmg ami ag the tatiem t: use her 

voluntary mushes in rearmg-d:— n mil ir mar" msTarses 'rrirg the 
mt: digital ::nr:l ir the vulva. It is at this time that sutplvum the tatiert 
with tra:t::r straps t: pull :r therery assisting in her rearmr- 1: ~~'u r ::o 
—ill ::ten 're :: assistarte 



MATE 3 :--! DYSTOCIA IN THE PARTURIENT TRACT - 

ADNEXA. 



III. RETENTION OF PLACE 7 AND MEMBRANES. 

Dennition. — The pla v — h : le — ith its memirares is sail t: 



: e:tp elled re mur 

termination :: the 

rents in : ehin 1 est 



a and mem': 
enta a::reta 
i.) This adhc 



is very rare Pig. 789). (2 A.1 



- - . . . 



uterus. A condil 



MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 



631 



of the uterus in the third stage of labor may be the cause of retention (Fig. 790). 
This state may be surmised if timely efforts to expel the placenta by Crede's 
method are unavailing. (3) Hour-glass contraction. By this expression is meant 
a contraction of Bandl's ring, which incarcerates the placenta, the fundus uteri 
remaining in a lax condition (Figs. 791 and 792). Schauta regards this condition as 





Fig. 789. — Retained Placenta 
from Adhesion to the Uterine 

• Wall. 



Fig. 790. — Retained Placenta from Atony of 
the Uterus. 




Fig. 791. — Retained Placenta from Tightening of the Contraction Ring. 
Form of "Hour-glass Contraction." 



One 



one of atony of the uterus despite the contraction of the ring. (4) Contraction 
of the external os (Fig. 793). (5) Tetanoid contractions of the entire uterus. 
This condition, which has been seen after the abuse of ergot, incarcerates the 
placenta for the time being (Fig. 794). (6) Actual incarceration of the placenta 
without regard to the uterine contractions is seen in certain malformations of 
the uterus (Figs. 467 to 476). (7) The foregoing causes refer to the entire pla- 



632 



PATHOLOGICAL LABOR. 



centa, but it is also possible, as already stated, for a portion of the placenta or 
membranes to be left behind through unskilful management of the after-birth 
period, and also despite all precautions. 




Fig. 792. — -Retained Placenta from 
Irregular Contractions of One 
Horn. One Form of "Hour-glass 
Contraction." 



Fig. 793. — Retained Placenta from Tighten- 
ing of the External Os. Follows the abuse 
of ergot. A common cause of the complica- 
tion. ' , :_^ ^ 




Fig. 794.— Retained Placenta from Tetanoid Contractions of the Entire Uterus. 






MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 633 

Symptoms and Diagnosis. — The principal symptom is naturally the non- 
expulsion of the placenta. If complete adhesion is present, there will be no 
hemorrhage. Examination of the fundus by palpation enables us to recognize 
the presence of uterine atony; and the association of vigorous contractions 
with the non-appearance of the placenta will cause us to suspect the presence 
of adhesion. More or less hemorrhage may accompany either atony or partial 
adhesion. In hour-glass contraction the fundus feels elastic, like an inflated 
balloon. After apparent expulsion of the entire ovum, the persistence of 
fragments of the decidual structures or the presence of a placenta succenturiata 
might be indicated by a persistent hemorrhage, expulsion of bits of tissue, 
after-pains, etc. 

Treatment. — Prophylaxis: This complication can usually be prevented by 
the proper management of the second and third stages of labor, but especially 
the latter. If the uterus is followed down with the hand on the fundus during 
the second stage and no traction is made upon the child to assist delivery; if 
the fundus is carefully held during the third stage and compression exerted 
only after the lapse of half an hour, and then only during uterine contraction; 
if no traction is made upon the cord and ergot administered only after the 
complete emptying of the uterus, retention of the whole or a portion of the 
placenta will rarely occur. Curative treatment: This will depend upon the 
amount of hemorrhage present. In the presence of profuse hemorrhage with 
retained placenta the indication is to empty the uterus completely by the 
quickest possible means ; for complete uterine contraction is the surest means 
to close the vessels and so to control the hemorrhage. Should Crede's method 
of placental expression fail, recourse must be had to digital or manual extrac- 
tion of the placenta. (See Operations, Part X.) 

IV. POST-PARTUM HEMORRHAGE. 

Definition. — Post-partum hemorrhage is hemorrhage from any portion of 
the parturient canal after delivery of the fetus. Post-partum hemorrhage 
proper is only from the placental site (Fig. 795). It is primary or immediate 
when it occurs within twenty-four hours after the expulsion of the child. It 
is secondary or remote when it occurs at any time during the puerperium subse- 
quent to the first twenty-four hours. Post-partum hemorrhage is also internal 
or concealed, and external or open. It may occur from the cervix, vagina, or the 
pelvic floor (Fig. 795). The typical form is commonly known as ''flooding." 

Frequency. — Severe cases of hemorrhage are not common, to judge from 
hospital statistics; but it must be remembered that proper facilities for treat- 
ment are there always at hand. This is by no means always the case in private 
practice. It may be stated in general that the complication occurs in a mild 
form once in fifty labors; is severe, once in 1000; and fatal, once in 5000. I 
found in 2200 cases of confinement, — 800 of which were outdoor, and the re- 
mainder hospital cases, — that post-partum hemorrhage occurred in 104 cases, 
or 4.72 per cent. This includes mild, severe, and fatal cases. The frequency 
of the accident in hospital and dispensary practice was about the same. Of 
these cases, 33.65 per cent, were in primiparae; 60.57 in multiparae, and 5.76 per 
cent, had no record of parity. Of the hemorrhages, 25.96 per cent, occurred 
before placental delivery; 62.50 per cent, after the completion of the third 
stage, and in 11.53 per cent, the hemorrhage took place both before and after 
delivery of the placenta. Of the foregoing, mild cases occurred once in 22 
labors; severe cases once in 550; and fatal cases once in 733^ labors. The 



63 4 PATHOLOGICAL LABOR. 

great frequency of the complication in the foregoing cases is due undoubtedly 
to the common use of the forceps (see Part X) and to the mismanagement 
of the third stage. (Page 543.) It is strange that this accident does not occur 
more frequently, especially in consideration of the characteristic structure 
of the uterine walls, and the alterations which have taken place in the pelvic 
blood-vessels and tissues during pregnancy. The conservatism of Nature is 
to be thanked for the escape of so many puerperal women. 

Mechanism.— The three processes which prevent post-partum hemorrhage 
from occurring more frequently than it does are (1) changes in the vessel-walls, 
(2) changes in the muscle-fibers of the uterus, and (3) changes in the blood. 
In pregnancy the blood-vessels of the uterine walls and of the broad ligaments 




Fig. 795. — Diagram showing the Four Varieties of Post-partum Hemorrhage 



and pelvic fascia are enormously dilated. In the uterus the vessel-walls grow 
very thin, and the external coats are gradually absorbed, until at the end of 
pregnancy the intima alone is left, which is surrounded by the hypertrophied 
muscle-fibers. The muscular fibers as pregnancy advances arrange themselves 
longitudinally in rows so as to form canals, in which the vessels run to join 
with the placental vessels. Besides the longitudinal arrangement of the fibers 
parallel with the vessels, the fibers in the latter months of gestation arrange 
themselves so as to form strong circular bands or sphincters encircling the 
vascular trunks. Thus each vessel runs in a muscular canal made up of con- 
tractile smooth muscle-fibers, and, in addition, falciform, sphincter-like bands 
of the same contractile fibers encircle several vascular trunks. This is well rep- 



MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 635 

resented by a package of cigarettes. There each individual cigarette is surrounded 
by its paper cover and the whole pack by its strong cover. This arrangement 
permits perfect obliteration of the blood-channels by uterine contraction. 
Besides, the intima is very elastic, which gives the vessel-wall the property 
of contractility, by which the ragged edges of the sinuses retract into the sub- 
stance of the uterus which covers them and stops up the apertures. The third 
process in Nature's conservatism is the increased coagulability of the blood. 
The blood-current is slowed in the great sinuses, and, owing to this and the 
extreme thinness of the vessel-walls, there is a marked tendency to diapedesis 
of white blood-corpuscles which proliferate in the connective tissue around 
the vessels and add their part to the obstruction of the lumina. When, there- 
fore, the decidua separates, this process hinders hemorrhage. On the other 
hand, there are (i) cases in which the uterus will remain comparatively large 
and flaccid and still no flooding result. (2) In many cases alternate contraction 
and relaxation of the uterus will take place after labor, and still no hemorrhage 
occur. This leads to the consideration of another preventive factor — thrombosis. 
In these cases of incomplete or partial contraction of the uterus the organ 
has sufficiently contracted to allow of the formation of coagula in the mouths 
of the uterine sinuses, so that when the uterus again relaxes, these openings 
are plugged by coagulated blood. 

Etiology. — Predisposing Causes. — Among these is the hemorrhagic diathesis. 
Some women are by nature "bleeders," and all through their pregnancy, par- 
turition, and puerperium they are subject to hemorrhage. Certain conditions 
of the mother's blood, as albuminuria, extreme malarial poisoning, leuco- 
cythemia, and alcoholism, strongly predispose to hemorrhage. Certain con- 
ditions of the liver, heart, and lungs which retard or obstruct the return cir- 
culation are also predisposing causes. It is more common in multipara? 
than in primiparae; the author, in 2200 confinements, found this hemorrhage 
twice as frequent in the former (60.57 per cent.) as in the latter (33.65 per 
cent.). It is apt to occur in those in whom menstruation is generally profuse 
— in women of a delicate constitution. Thus it is seen among the rich rather 
than among the hard-working classes; in delicately nurtured women who 
have cultivated the emotional at the expense of the physical. It also occurs 
in women of the temperate zones who have taken up their residence in the 
tropics and have become debilitated by the warm climate. Irregularities in 
the maternal forces, such as precipitate or protracted labor, also lead to post- 
partum hemorrhage; so does overdistention of the uterus, as in multiple preg- 
nancies and hydramnios. Certain conditions of the muscular walls of the 
uterus, degenerations, tumors; or malposition of the organ, partial or com- 
plete inversion, also favor post-partum hemorrhage. 

Exciting Causes. — Foremost among these is the improper treatment of 
the second and third stages of labor. This complication is, almost without 
exception, the attendant's fault, and applies to the too rapid emptying of 
the uterus, as in extraction in breech presentations, and the use of forceps, 
cranioclasts, or cephalotribe, or by too rapid extraction after turning, and 
the excessive use of anesthetics — chloroform or ether. Here also belong efforts 
on the part of the attendant to hurry delivery by uterine compression, and 
injudicious voluntary efforts on the part of the patient during the second stage ; 
as, for example, too forcible bearing-down during the hard pains. Mental 
emotions, such as anger, fright, anxiety, and such disturbances as coughing, 
laughing, vomiting, defecation, etc., have been known to give rise to post-partum 
hemorrhage. A distended bladder or rectum often constitutes an exciting cause. 



636 PATHOLOGICAL LABOR. 

The retention of the placenta, membranes, or blood-clots, or new growths 
in the uterus, may hinder its contraction. A uterus completely and perma- 
nently contracted cannot give rise to a severe hemorrhage. Other factors are: 
uterine apathy; imperfect development of the organ or a deficient nerve- 
supply to it; adherent placental tissue; a large pyosalpinx, hydrosalpinx, 
pelvic exudate, old adhesions of the peritoneal surface of the uterus, or any 
mechanical obstruction to uterine contraction. Placenta praevia may be the 
cause of post-partum hemorrhage, for the lower uterine segment has not the 
power to contract that the upper part of the organ has, hence when the placenta 
is attached here the open mouths of the vessels do not close so quickly. 

Symptoms. — The symptoms in many cases come insidiously — all may 
apparently have gone well, and the placenta expelled naturally, but soon after, 
the first symptom perhaps will be a complaint from the patient that she "feels 
faint," and that "something is flowing away from her." This warning should 
never be disregarded, and an immediate examination should be made. There 
may be only a slight discharge or the blood may be escaping in torrents. On 
palpating the uterus it is found to be soft, flaccid, and flabby, rising to and 
perhaps above the umbilicus, and presenting hard, irregular prominences which 
shift their position under a firm grasp. These are blood-clots within the uterus. 
In the more severe cases in which uterine inertia is complete, external pal- 
pation will not discover any uterus at all. Alternate contractions and re- 
laxations of the uterus, together with pain and tenderness when the fundus 
is firmly grasped, are certain signs of hemorrhage from atony of the muscular 
fibers. There may be slight open or external hemorrhages taking place for 
some time before any general symptoms are produced, and the patient not 
complaining, the physical signs will be overlooked. In extreme cases, however, 
of the concealed or the open variety, the general symptoms of shock and col- 
lapse set in, and it seems impossible to cause the uterus to contract immediately. 
In sudden profuse hemorrhages death may occur within two or three minutes. 
Frequency of the pulse-rate and decreased force are valuable danger-signals 
of the condition, and when observed should demand a careful examination of 
the uterus and the discharge. 

Diagnosis. — The diagnosis is generally plain, especially when the bleeding 
is external. It is different when the blood accumulates within the uterine 
cavity, which constitutes the concealed variety, for although there are then 
the symptoms of syncope and collapse and a more or less rapidly enlarging 
abdomen, yet these symptoms and signs may be present without internal 
hemorrhage, (i) Syncope occurring after labor does not always depend upon 
loss of blood. It is often observed after precipitate and very rapid labors, 
for in these cases the uterus is so quickly emptied that the pressure to which 
the abdominal vessels had been subjected in the last two months of pregnancy 
is suddenly removed; the circulation in them becomes free and unobstructed 
and there is a rapid determination of blood from the upper part of the body, 
giving rise to cerebral anemia and fainting. When this occurs, raising the 
foot of the bed and the application of a moderately tight abdominal bandage 
will usually relieve the condition. (2) Enlargement of the abdomen may be 
owing to the fact that the intestines, being suddenly relieved of pressure and 
distended by gas, cause the abdominal wall to swell up nearly to its previous 
size. But in this case careful physical examination by palpation, percus- 
sion, and vaginal touch will readily determine the true state of affairs. (3) 
An hysterical attack coming on immediately after labor may be mistaken for 
the general symptoms of hemorrhage; but physical examination will again 



MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 637 

distinguish the well-contracted uterus in the hypogastrium. (4) Lacerations 
of the cervix causing rupture of the circular artery or lacerations of the genital 
tract below the cervix may be mistaken for post-partum hemorrhage. In these 
cases there will be a firmly contracted uterus. If any doubt exists, a speculum 
can be passed and the bleeding point treated. If the hemorrhage does not 
occur within ten or fifteen minutes of the birth of the child, it is not usually 
due to cervical or vaginal tears. Engel (1840), Schraeder, Virchow, Valenta, 
and Olshausen have described a dangerous variety of hemorrhage: viz., in 
cases in which, although the rest of the uterus is firmly contracted, the place 
of placental insertion does not participate, and there results what might be 
termed paralysis of the placental site. The part involved is driven down 
into the uterine cavity by the uterine parenchyma which is contracted about 
it like a ring, and thus a sort of tumor is formed which projects into the uterine 
cavity, and at a corresponding point upon its external surface a depression 
may be made out by careful palpation. This variety is particularly danger- 
ous, because, the greater part of the uterine globe being firmly contracted, 
this small relaxed part may escape observation. Rarely an uncontrollable 
post-partum hemorrhage occurs from a firmly contracted and uninjured uterus. 
One case is on record in which it occurred from an aneurysmal vessel; another 
from a rupture hematoma of the cervix ; and a third from a lacerated varicose 
cervical vein. These complications are said to be more common in high than 
in low altitudes on account of lessened atmospheric pressure (Hirst). 

Prognosis. — The prognosis is doubtful, as it depends on several factors. It 
is the graver, the earlier the hemorrhage takes place. There is great danger in 
that variety in which by the formation of a vaginal or cervical clot or the intro- 
duction of a tampon it becomes hidden. If the blood is like serum, not clotting, 
there is immediate danger of death. Pain in the back is taken as an encouraging 
sign indicating uterine activity. Other things being equal, the prognosis is 
more dangerous in the internal variety than in the external, for in the former 
the flow is apt to escape detection. There, again, the prognosis will vary 
depending on the completeness of the uterine inertia, and whether the patient 
is to have immediate and skilful treatment, for a very few moments may decide 
the patient's fate. The late results of the hemorrhage are the same as those 
from any severe hemorrhage. 

Treatment. — Preventive. — In case the pregnant woman is suffering from 
albuminuria, leucocythemia, or alcoholism, the condition should be treated, 
so that when the time of delivery draws near, the nervous, muscular, and cir- 
culatory systems of the patient may be in as good a condition as possible. 
All causes of obstructed venous return should be sought out, whether resident 
in the liver, heart, or lungs, and remedied as far as possible. Women worn 
out with frequent child-bearing and the attendant nursing and anxiety should 
be strengthened by iron, fresh air, nourishing food, and moderate exercise. 
When there is reason to fear precipitate labor, the patient should not go about 
without a nurse properly qualified to manage the delivery. In attending 
such a case before the child's birth delay should rather be encouraged so that 
the uterus may not be emptied too rapidly and the danger of uterine inertia 
increased. In cases of protracted labor the physician should not delay till 
the patient is exhausted before he renders assistance. A case of hydramnios 
should not run too far; rather should the membranes be ruptured when labor 
appears about to progress smoothly. The most important part of the pre- 
ventive treatment is the proper management of the second and third stages 
of labor. The hand should not leave the fundus after the birth of the child 



638 



PATHOLOGICAL LABOR. 



till the placenta is expelled, and uterine contractions should be watched care- 
fully afterward for at least an hour. Any disturbance of the patient during 
this time should be avoided, and the administration of a drachm of the fluid 
extract of ergot after complete emptying of the uterus adds to the safety and 
comfort of the woman. The placenta and membranes should be carefully 
examined after their expulsion. An abdominal binder should be applied im- 
mediately and the child placed to the breast within three hours of the com- 
pletion of labor. 

Curative Treatment. — The curative treatment is more satisfactory than 





Fig. 796.— Compression of the Fundus for the Emptying of the Uterus and thi 
Control of Post-partum Hemorrhage. 



that of any other obstetrical complication. The mechanism by which the 
condition occurs must be carefully borne in mind ; whence it will appear that 
successful management must fulfill three indications: viz., (1) The uterus 
must be evacuated; (2) it must be made to contract completely; (3) the loss 
of blood and its consequences must be made good by measures directed to 
the relief of the acute anemia. (1) Evacuation of the uterus: The uterus in these 
cases usually contains fragments of placenta, membranes, or blood-clots which 
must be brought away. Crede's movements (See Operations) are therefore 
instituted in the same manner as in the expulsion of the placenta (Fig. 796). 



MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 



639 



In kneading the uterus the fundus is at the same time conpressed, while the 
ulnar bolder of the operator's hand makes pressure on the abdominal aorta. 
The hand is introduced into the uterine cavity only when the Crede' method 
fails in its purpose. (2) Permanent contraction of the uterus: The rules for bring- 
ing this about are in part a continuation of the preceding. Compression of 
the fundus uteri and of the aorta is maintained, or Breisky's method of bimanual 
compression of the uterus may be employed alternately (Fig. 797). Another 
method of bimanual compression (Gooch's) is also recommended (Fig. 798). 
It consists in compressing the fundus with one hand while the other, tightly 




Fig. 797. — Bimanual Compression of the Uterus for the Control of Post-partum 
Hemorrhage. The fingers of the left hand can, at the same time, compress the 
abdominal aorta. 



closed, occupies the uterine cavity. When for any reason the hand is intro- 
duced within the uterus, it should be withdrawn only during a contraction lest 
air entering a sinus cause fatal pulmonary embolism. The management thus 
far given should be sufficient in most cases to arrest all hemorrhage. It is 
eminently natural management, since it aids and imitates Nature's methods. 
However, it is not invariably successful, for a degree of atony sometimes exists 
which cannot be made to yield to mechanical excitation. In such a case the 
uterine cavity should be douched with hot water, either plain or with the addi- 
tion of 1 per cent, acetic acid. About one quart of water should be injected 
at a temperature of 120 F. (49 C). In an emergency hot or cold vinegar 



640 



PATHOLOGICAL LABOR. 



may be used in place of the acidulated water. The alternate use of hot and 
cold water or ice has been advocated in these cases, but cold in the uterus is 
a depressant, and adds to the shock of the hemorrhage. There is no objection, 
however, to the application of cold to the vulva. If the styptic douche is 
ineffectual,— and many obstetricians would hardly resort to it after failure 
of physiological treatment ,— the uterine cavity and the vagina must be tam- 
poned with gauze. (See Tamponade of Uterus, Operations, Part X.) The 




Fig. 798. — Bimanual Compressiox of the Uterus. The Left Hand, in the Shape 
of a Fist, is Introduced into the Uterine Cavity, and This is Grasped by 
the Right Hand through the Anterior Abdominal Wall. 



tampons should be removed in about six hours. As an adjuvant to the measures 
just described, ergotin may be injected subcutaneously. Styptics to the uterine 
cavity are contraindicated with the exception of those enumerated. (3) Treat- 
ment of anemia and shock: This is directed especially to the acute anemia and 
tendency to heart failure which are produced by loss of blood. If the severity 
of the symptoms is such as to warrant the most active treatment, the pillows 
are removed from the bed, the foot of the bedstead is elevated, and the patient's 
arms and legs are bandaged (autotransfusion). Warm saline infusion is then 



MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 641 

introduced into the rectum and subcutaneously beneath the breasts. (See 
Operations, Part X.) Stimulants must be used with care owing to their tend- 
ency to cramp the heart under these circumstances. Ammonia may be injected 
into a vein, and camphorated oil subcutaneously. Absolute quiet is demanded. 
Feeding must not be neglected in these cases. At first it may require limitation 
to sips of brandy and coffee every fifteen minutes; after some reaction has set 
in, beef -juice, panopeptone, mutton broth, etc., may be substituted. In case 
of vomiting the patient may be nourished by the rectum with enemata of hot 
water containing whisky and pancreatinized milk or panopeptone. 



V. RUPTURE OF THE UTERUS. 

Definition. — A partial or complete rupture of some part of the uterine wall 
occurring during pregnancy, labor, or the puerperium. So-called spontaneous 
rupture may occur during pregnancy from rapid stretching of the uterine walls 
or from cystic degeneration of the chorion. These latter ruptures are very 
rare and result almost invariably from traumatism. Intra-partum rupture is 
rupture of the uterus proper. Rupture may also occur during the puerperium 
from a dissecting metritis in septic conditions, or from sloughing following 
prolonged pressure of the fetal head during labor. This is also very rare and 
is nearly always traumatic, e. g., from post-partum curettage. 

Frequency. — It occurs about once in iooo cases of confinement. A case 
might not be met with in a decade, while, again, one observer might see two 
in the same day. However, this accident is far more frequent than is generally 
stated. A great proportion of those in private practice which end fatally 
are reported as post-partum hemorrhage or as septic peritonitis. It is only 
in maternity hospitals that anything like correct statistics can be compiled. 

Pathology. — On account of the general right obliquity of the uterus, the 
retraction is greater on the left side than on the right. In shoulder presenta- 
tion, also, the head is most often on the left. These facts probably explain 
the general direction of the ruptures and their greater frequency on the left 
side. The cause for the frequency of rupture on the posterior wall is the direc- 
tion of the force of uterine contractions. When the rupture is in the lateral 
wall, the peritoneum is generally felt intact, for its attachment in this situation 
is loose and the folds of the broad ligament near the uterus are separated to 
a certain degree by the growth of that organ during pregnancy. As a rule 
the edges of the rupture are not clean-cut, but are rough and jagged, and the 
direction is often oblique (Fig. 800). The prevailing low situation of the rupture 
depends on the greater distention and thinning of this part of the uterus during 
labor (Figs. 537 and 538). The degree of the tear varies from the size of a 
finger-tip to an opening large enough for the fetus to pass through. A trans- 
verse rupture sometimes embraces all or nearly all of the circumference of 
the organ (Fig. 800); a longitudinal or oblique tear may extend downward 
into the vagina or upward into the fundus of the uterus (Fig. 799). If the 
rupture is quite large and the uterine contents are evacuated, the upper part 
of the organ firmly contracts, while it is forced out of its normal position by 
the fetal body, which lies in the abdominal cavity. The manner of escape 
of the fetus varies in different cases. In a large tear it, together with the pla- 
centa, may be extruded into the cavity; or, again, if its head is impacted in 
the pelvis, it may be only the trunk and extremities which lie outside the uterus. 
In some cases the placenta remains in the uterus and is delivered through the 
41 



642 



PATHOLOGICAL LABOR. 



vagina. Incomplete rupture consists of partial or almost complete rupture of the 
muscular coat. Complete rupture involves muscle and peritoneum. From the 
former may result extrauterine and extraperitoneal hematocele. Very rarely 
rupture of the peritoneum alone occurs. The complete rupture consists in 
a communication between the cavities of the uterus and peritoneum. The 
rupture is called complicated when there is associated an injury of a neighbor- 
ing organ ; for example, an opening into the bladder or intestines. 



RIGHT 
OVARY 



OVARIAN 
VESSELS 




uter ine _ ^u 
vesseTs^ 



ANTERIOR 
'SURFACE 



INTERNAL OS 



Fig. 799. — Longitudinal Rupture of the Uterus, Following Manual^ Dilatation 
of the Os in Placenta Previa. Tearing of the main branches of the uterine artery 
and death from internal hemorrhage. Note that the cervical canal and the limit 
of the internal os are still present. — {Author's case.) 



Etiology. — Among the predisposing causes are disproportionate size of the 
head and pelvis, stretching of one side of the lower uterine segment from lateral 
displacement, and any force which tends to twist the organ upon its longitudinal 
axis. Schuchard (1884) found among 73 cases of hydrocephalus, 14 cases 
of rupture of the uterus. A shoulder presentation is responsible for a large 
proportion of cases of rupture of the uterus, and it is possible for the cervix 
to be so rigid that rupture occurs before the cervix yields. Contributory 
causes of rupture are anything which narrows and makes rigid the cervical 



MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 643 

or vaginal canals (healed fistulas or lacerations, new growths, etc.); pathological 
change in the uterine tissue (syphilis, soft myoma, carcinoma). Placenta 
prsevia may also act as a cause. The scar of a previous Cassarean section 
has been known to be a cause. Rupture occurs seven times as often among 
multiparas as among primiparae. Among 19 cases Bandl found 2 primiparae, 
and others have given the percentage of primiparae as 12 or less. 

The exciting causes include the unintelligent use of ergot. A number of 




\ Round ligament. 
\Main branch of uterine 
artery drawn up. 



Fig. 800. — Transverse or Oblique Rupture of the Uterus and Tearing of a Main 
Branch of the Left Uterine Artery. Death from internal hemorrhage and shock 
a short time after being received into the Emergency Hospital. Case had been treated 
for inertia with ergot by a midwife. — {Author's case.) 



cases of rupture have occurred from intrauterine manipulation, curettage, 
version, extraction of placenta, etc., criminal abortion. Rupture occurring 
during pregnancy is due to some pathological change in the uterine wall or 
to a new growth. Wittrow (1891) reported a case of rupture from external 
violence. The peritoneum and the muscular coats were torn but not the mucosa. 
Cases of rupture have been reported which occurred after the placenta was 
removed, from clumsy and violent manipulations by the accoucheur or mid- 



644 PATHOLOGICAL LABOR. 

wife. The site of the rupture is usually lateral and on the left side, correspond- 
ing to the position of the vertex. The body of the organ is seldom torn. There 
are two methods in the mechanism of spontaneous rupture: (i) Rupture by 
thinning of the lower segment. In proportion to the variation between the 
expelling power and the resistance, thinning of the lower segment takes place 
while it closely hugs the enclosed fetus until rupture occurs. (2) Rupture by 
compression of the uterine wall. The wall sometimes ruptures from the com- 
pression to which it is subjected between the bony pelvis and the presenting 
part. 

Symptoms. — Impending: The most characteristic symptoms are the ascent 
of the contraction ring and the tension and tenderness of the round ligaments. 
Pulse and temperature may not be changed, but the patient may develop 
great anxiety and restlessness. Thickening of the upper portion of the uterus, 
and a transverse groove across the lower portion, can often be recognized through 
the abdominal wall, the latter just above the pubis. The uterine contractions 
will be strong or even tetanic, in either case accompanied by intense pain. 
There is often a history of previous prolonged, obstructed labor due to pelvic 
deformity, with entire escape of the liquor amnii causing dry labor. The 
symptoms of rupture are very characteristic, especially when complete. There 
is a sharp, acute pain; a sudden cry from the patient; sometimes a sound of 
tearing tissue; followed by immediate collapse and symptoms of internal 
hemorrhage. External hemorrhage, recession of the presenting part, prolapse 
of the intestines, and subperitoneal emphysema are sometimes present. Col- 
lapse is soon marked ; the pain severe ; the pulse small and rapid ; the patient 
usually vomits and the uterine contractions cease, though the latter is not an 
invariable occurrence. In the case of a head presentation the head often recedes 
from the pelvis even if it is already engaged. In shoulder presentation the 
head may sometimes be felt through the tear, and it will be noted that the 
form of the uterus has suddenly altered. In some cases the fetus may leave 
the uterus entirely and may be palpable through the abdominal walls. Even 
in rupture of considerable extent the hemorrhage may be slight or even absent, 
and there may be no external evidence of it, especially when the head is firmly 
engaged. The claim that collapse after delivery means rupture of the uterus 
is sound, but there are cases in which there is extensive rupture" without col- 
lapse, and such conditions are readily unrecognized. Patients have often 
experienced a sensation of tearing, and in several instances have described 
it to me as of " something giving way." The hemorrhage which nearly 
always occurs may be external or internal. In proportion to the severity of 
the hemorrhage will the symptoms be grave. Symptoms of peritonitis come 
on very quickly. Terminations are: (1) cicatrization and healing; (2) rapid 
death from hemorrhage and collapse; (3) retarded death from peritonitis and 
septicemia. 

Diagnosis. — When the foregoing symptoms have made their appearance, 
physical exploration will confirm the diagnosis. (1) Auscultation shows cessa- 
tion of fetal heart-sounds, as the fetus generally dies. (2) Vaginal palpation 
is normal as long as the fetus is still within the uterus, but if it has passed partly 
or completely into the abdominal cavity, the presenting part is out of reach. 
(3) Abdominal palpation: The uterus preserves its form if the fetus remains 
in it. Pressure increases the pain at the point of rupture. The painful region 
may be emphysematous. If the fetus has escaped partly or completely into 
the abdomen, there will be two tumors — one the fetus, and the other the re- 
tracted uterus. (4) Direct examination of the uterine cavity. The location 






MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 



645 



and extent of the rupture may be discovered in this manner. Sometimes 
there is hernia of the intestine which becomes strangulated in the uterine wound. 
There are cases of uterine rupture which would have been overlooked if the 
physician had not been obliged to deliver artificially. The condition may 
be confounded with placenta praevia and accidental hemorrhage. (Pages 225 
and 237.) 

Prognosis. — This is the most serious complication in obstetrics ; the maternal 
mortality may be placed, in complete rupture, at 90 per cent.; the fetal mor- 
tality at 95 per cent. Maternal death is due to shock, primary or secondary 
hemorrhage, peritonitis or septicemia; fetal 
death is due to asphyxia from interference 
with the placental circulation. The foregoing 
maternal mortality is estimated from the un- 
relieved cases. This is diminished under 
modern methods of treatment, being placed 
at from 55 to 60 per cent. One reason for 
the very unfavorable course of most cases is 
that the patients are already seriously weak- 
ened and usually infected before the accident 
occurs. In incomplete ruptures in which the 
peritoneal coat is not torn the prognosis is 
naturally much more favorable than in the 
complete, and they occur more frequently than 
is generally supposed. Rupture may occur 
also down to the mucosa from the peritoneal 
side. Anterior ruptures may also involve the 
bladder, and are therefore more serious. The 
gravity of the case is increased by complica- 
tions. If the rectum or bladder is lacerated, 
there will be an escape of the contents into 
the surrounding tissues. There may be hernia 
or incarceration of the intestine with subse- 
quent gangrene. There may be rupture of an 
hematocele, and death from hemorrhage or 
septic peritonitis may follow the suppuration 
of this mass. 

Treatment. — Prophylactic Treatment. — 
This is most important. All cases having 
obstructed or prolonged labor from any cause 
must be watched for tetanic or cramp-like 
action of the uterus, retraction, or dangerous 
thinning of the lower uterine segment, in order 
that artificial aid may be given before rup- 
ture actually occurs. When rupture is threatening, the strength of the labor 
pains must be diminished by chloroform or morphin and any malposition 
of the uterus or fetus must be corrected. All obstetrical work must be carried 
out with the greatest caution, especially the application of the forceps. Some 
cases will demand perforation; some in which the presentation is a shoulder, 
may require decapitation, invariably or only when the child is dead. Version 
is usually attempted when the child is alive. Cassarean section may be required 
when rupture is threatening and delivery does not seem practicable by other 
means. In nervous patients with a tendency to tetanoid contraction of the 




Fig. 801. — Complete Rupture of 
the Uterus Involving Left Lat- 
eral and Posterior Walls and 
Extending from the Contrac- 
tion Ring almost to the Ex- 
ternal Os, Which Latter is In- 
tact. Also complete rupture of 
posterior vaginal wall just below 
external ring, opening into Doug- 
las's pouch. — (After a specimen in 
the Museum of the Munich Frauen- 
klinik.) 



646 PATHOLOGICAL LABOR. 

uterus the wise use of anesthetics will often result in a favorable course. When 
slight pelvic contraction has been diagnosticated, the state of the uterus during 
its contractions must be carefully watched; and as soon as the contraction ring 
rises, labor should be quickly terminated by forceps or craniotomy. Decapita- 
tion is the only allowable method in neglected shoulder presentation. In all 
cases where rupture is impending, labor must be ended by the method safest to 
the mother, regardless of the fetus. If the head is immovable, the use of the 
forceps is in order. But if the head is movable and version contraindicated, 
the forceps will most likely injure both mother and child. All violent manipu- 
lations should be avoided. In threatened rupture, embryotomy is preferable to 
version, for the introduction of the hand as well as the turning of the child is 
very dangerous when the uterus is in this condition. In cases of hydrocephalus 
perforation is indicated. The chief complications which are followed by danger 
of rupture are contracted pelvis, hydrocephalus, and shoulder presentation. If 
in neglected shoulder presentation version is suggested, it should be ascertained 
whether the fetus is still living. In order to make this certain the hand, if pos- 
sible, should be passed up almost to the shoulder and the cord palpated for pul- 
sations. Version is not performed in case of a dead fetus. 

Curative Treatment. — If rupture has already occurred, no disinfecting douche 
is to be used, and the rupture must not be allowed to increase. Version must 
not be attempted in the presence of a rupture with the fetus still in the uterus. 
The rupture 'might be made larger and the perhaps untorn peritoneum torn 
through. If the fetus is partly protruding into the abdominal cavity, delivery 
is still possible through the vagina, but it is an uncertain operation. Most 
authorities agree that operation is the best treatment for the majority of cases, 
though Braun thinks that some can be treated by uterine tamponade, when the 
tear is not too great, when the placenta remains in the uterus, and when there 
is no sepsis. If operation is decided upon, the uterus is better extirpated 
when there is infection of the endometrium, when there is great anemia, and 
in cases in which the laceration is extreme or the peritoneum freely stripped 
up. The after-treatment is like that of an ordinary Porro hysterectomy. 
When the uterus is not removed, the best treatment for the laceration is suture. 
Many successful cases have been reported. Various sets of statistics give 
a mortality rate for the operative treatment of rupture at from 25 to 50 per 
cent. Laparotomy, if the patient is in fair condition, in these days of anti- 
septic surgery is attended by very good results. Some authorities believe 
laparotomy to be indicated in all cases of complete rupture and when there 
is serious hemorrhage from an incomplete one. In cases in which the operation 
does not seem indicated the treatment is, after delivery, tamponade of the 
uterus with sterile gauze. When there is infection, the wound must be at 
least partly left open and treated by tamponade. Incomplete ruptures treated 
by tampon must also be treated by external abdominal pressure. This method 
of tamponade is said by some to make possible a subperitoneal hematoma, 
and pressure assists in preventing this. Ruptures extending upward into the 
supravaginal portion of the uterus are especially liable to be accompanied 
by serious hemorrhage, from which placenta prsevia is to be differentiated. 
The hemorrhage from such lacerations may be very troublesome and dan- 
gerous, and it may be necessary to open the posterior vaginal fornix and 
clamp the broad ligaments in much the same way as in a vaginal hysterectomy. 

Summary of Treatment. — (1) Curative treatment should always be prompt 
and active; expectant treatment is usually fatal to the mother and always 
to the fetus; the fetus must be delivered by some method — podalic version, 



MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 647 

forceps, or craniotomy if dead — that will cause as little shock as possible. (2) 
A careful examination of the position and extent of rupture must be made. 
(3) If the latter is small, low down, posterior, and meconium and clots have 
not escaped into the peritoneal cavity, the uterine cavity must-be freely irrigated 
with warm sterilized water, and a good-sized strip of sterile gauze passed to 
the fundus, a firm abdominal binder applied, full doses of ergot administered, 
and the case treated expectantly. One should be prepared for laparotomy 
on the first indication of peritonitis. (4) Large ruptures with escape of the 
fetus into abdominal cavity, and ruptures high up in the uterine wall, are 
best treated by removing the child by the natural passages if possible and 
immediately performing laparotomy and hysterectomy, or, instead of the 
latter, Sanger's operation. 

After-treatment. — The after-treatment is upon general principles. If re- 
covery follows and subsequent pregnancy occurs, it should be terminated at the 
thirty-sixth week to avoid spontaneous rupture. 



VI. INVERSION OF THE UTERUS. 

Definition. — By inversion of the uterus we mean a complete or partial 
turning of the uterus inside out. It may occur before or after the delivery 
of the placenta. It is the rarest of all complications of labor, occurring once 
in 200,000 cases, and may be partial or complete. It generally begins by 
a slight depression of the fundus. In a hospital experience of many thousand 
cases of confinement no case of complete inversion has occurred. I have seen 
in consultation practice several cases of partial inversion. 

Etiology. — It is most common in primiparae and is due to the so-called 
paralysis of the placental site, too vigorous compression of the fundus, or traction 
on the cord. Mismanagement is generally responsible for this complication. 
Other causes are sudden delivery, especially when the patient is standing 
and the uterus relaxed; exertion after delivery, such as coughing or straining; 
heavy pressure on the fundus from above; or a short cord, from whatever cause. 
The uterus must be relaxed, for inversion of a well-contracted uterus is almost 
inconceivable. This accident generally takes place during the third stage of 
labor, although rarely it may happen days after delivery. In very rare cases 
this complication may exist without reproach to the physician. 

Symptoms. — These are acute pain, hemorrhage, and shock; imperceptibility 
of the fundus through the abdominal wall and a cup-like body in the vagina or 
protruding through the vulva (Figs. 802, 803). The hemorrhage may be slight 
or profuse according to whether the uterine sinuses are closed or open. There is 
a rapid, thready pulse, the skin is clammy and pale, and nausea, vomiting, and 
even syncope may occur. Reflex cardiac paralysis and cerebral anemia may 
result. Most rarely this complication may occur with no apparent symptoms. 

Diagnosis. — Inversion may be confounded with uterine polyp. The latter 
is insensible and does not contract on examination, and its pedicle may be 
traced upward through the os uteri into the cavity and demonstrated with 
a sound. The patient should be catheterized to set aside the possibility of 
a distended bladder. If the physician is present when the accident occurs, 
and if the placenta is wholly or partially attached to the uterus, the diagnosis 
is clear. The opening of the tubes may be seen on the lower part of the tumor. 
The uterus is generally particularly sensitive and contractile. An inverted 
uterus can always be half reduced; polyps cannot. Rectal examination will 
detect absence of the uterus from its normal position. 



648 



PATHOLOGICAL LABOR. 



Prognosis. — Mortality is as high as 50 per cent. Death, due to either 
hemorrhage or shock, often occurs soon after the accident (within half an 
hour). It may also be caused by incarceration of an intestinal loop in the 
inverted uterus, by peritonitis, by puerperal infection, or by gangrene. Cases 
are on record in which recovery has taken place after the uterus has sloughed. 
A few cases in which manual reposition was not accomplished were spontaneously 
restored. The prognosis depends largely upon prompt reduction of the organ, 
as delay increases the danger and difficulty. Prognosis should always be 
guarded. 

Treatment. — The accident can usually be avoided; hence the prophylactic 
treatment is most important. Precipitate expulsion of the fetus should be 
prevented and unnecessary force in Crede's method and in traction upon the 
cord avoided. Curative treatment con- 
sists in the immediate reduction of the 
tumor with the aid of anesthesia. The 





Fig. 802, 



-Beginning Inversion of the 

Uterus. 



Fig. 803. — Inversion of the Uterus. 



bladder and rectum should be emptied and reduction accomplished by taxis, 
followed by intrauterine irrigation and tight intrauterine tamponade. The more 
quickly treatment is instituted, the more successful the result. When the 
placenta is completely adherent or nearly so, an attempt should be made to 
replace it with the uterus, although this is a disputed point. The fist 
should be placed against the inverted fundus while the other hand makes 
counter-pressure over the abdomen. If the placenta be almost separated 
or if it interferes with reduction, it must be entirely detached. When the 
body of the uterus has become swollen and congested, it is compressed either 
manually or by bandaging before it is reduced. If this is impossible on account 
of spasmodic constriction of the os, anesthesia may relax the spasm. Pressure 
firmly continued gives the best results. After reduction has been accomplished 



MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 649 

the uterus must contract before the hand is withdrawn, and if the placenta 
is still attached it should be separated. Some authorities advise, in replacing 
the uterus, to begin with that part which was last inverted. In cases in which 
the uterus cannot be restored without great shock to the patient, especially 
if she is not seen until several days have elapsed, the operation should be delayed 
temporarily. If the uterus cannot be returned, hemorrhage can be controlled 
by ergot and the local application of astringents, such as acetic acid, and stimu- 
lating contractions by putting the child to the breast. 

VII. EXCESSIVE RIGHT LATERAL OBLIQUITY OF THE UTERUS. 

Although it is a physiological fact that the uterus leans as a rule to the 
right side in pregnancy, this position is sometimes exaggerated so that much 
of the expulsive power is wasted by driving the presenting part against the 
lateral pelvic wall, resulting in delayed labor, malpresentations and malpositions, 
and even in uterine rupture (Fig. 800). Postural treatment by placing the 
patient on the left side is usually sufficient to relieve the condition. 

VIII. LACERATIONS AND CONTUSIONS OF THE CERVIX, VAGINA, 

RECTUM, AND PERINEUM.* 

1. Lacerations and Contusions of the Cervix. — The cervix is ruptured very 
frequently during labor, this accident invariably occurring in primiparas. The 
scars resulting from lacerations of the cervix constitute one of the essential 
evidences of previous pregnancy (Fig. 123). 

Etiology. — The mere act of labor itself is the cause of the milder degrees of 
laceration, the injury occurring during the expulsion of the head, shoulders, etc. 
Deeper tears have a different cause. There is usually a predisposition in the 
shape of organic rigidity. Precipitate or premature expulsion of the fetus before 
dilatation is complete and operative extraction under the same condition both 
produce extensive injuries. Many lacerations are due to forceps deliveries and 
version, but especially to the unskilful use of instruments. 

Symptoms. — The vast majority of tears are longitudinal, involving the os, 
but circular lacerations have been described (Fig. 806). In one of the author's 
cases of anatomical rigidity the entire portio was torn from the rest of the uterus 
(Fig. 804). Ordinary longitudinal tears may be single, bilateral, or multiple, the 
latter being rare. Deep lacerations of the cervix may extend into the vaginal 
culs-de-sac (extraperitoneal rupture of the uterus). Finally, there is a sub- 
mucous rupture, which is manifested by a patulousness of the os. Clinically 
the principal symptom of ruptured cervix is hemorrhage. In the deeper 
varieties some of the large branches of the uterine artery may be torn. Cervical 
lacerations often heal spontaneously during the puerperium. The diagnosis is 
made by careful inspection and palpation. As regards prognosis, after the 
cessation of hemorrhage there is still danger of infection, and of the develop- 
ment of cervical catarrh, with resulting tendency to abortion. 

Treatment. — The prophylaxis consists in the utmost care in all operative 
procedures which involve either forcing or drawing the fetus through an imper- 
fectly dilated os. In regard to treatment proper, hemorrhage must be arrested 
if profuse, and the best method is by immediate suture of the tear. In suturing 
extensive lacerations through the vagina, not only may the attempt fail, but 
there is a strong possibility of endangering the ureters. 

* Compare Operations, Part X. 



650 



PATHOLOGICAL LABOR. 



2. Lacerations and Contusions of the Vagina (see Repair of Injuries, Part X). 
— These injuries may be either spontaneous or artificial in origin. The lower 
third is implicated much more commonly than the rest of the passage. Next in 
order comes the upper third (culs-de-sac), and lastly the middle third. 





Fig. 804. 



Fis:. So= 



Figs. 804 and 805. — Author's Cases of Annular Detachment of the Cervix. The 
left-hand figure was in the case of a generally contracted pelvis, and the other was 
due to incarceration of the anterior lip of the cervix between the advancing head 
and the symphysis. 



Etiology. — Lacerations of the lower and middle thirds are due, as a rule, to 
the marked transverse distention of the vagina by the presenting part. These 
vaginal tears a~e usually longitudinal at the junction of the posterior with one 

of the lateral walls. Lacerations of 
the upper third are due to causes 
practically the same as those for 
rupture of the uterus, with which 
they are also clinically related. 
Submucous rupture is usually due 
to the sudden descent of the head 
in precipitate labors and forceps ex- 
tractions. Many lacerations occur 
from operative delivery. A spe- 
cial form of injury to the vagina — 
a contusion rather than a lacera- 
tion — is seen in the upper third in 
certain deformities of the pelvis in 
which bony projections encroach 
upon the excavation. Thus the 
ischial spines project into the fun- 
nel-shaped pelvis and the crest of 
the os pubis in exostosis pelvis. The 
vagina then becomes incarcerated 
between the fetal head and the 
bony prominence. Similar contusions are seen when the fetal head is 
arrested in a narrow pelvis, and if the bladder is incarcerated between the 
fetal head and the symphysis a vesico-vaginal fistula may result (Figs. 




Fig. 



806. — Laceration of the Cervix during 
Labor. 



MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 



651 




B 

R 
B' 



Fig. 807. — Utero-vesical Rupture Due to Secon- 
dary Inertia in Persistent Occipito-posterior 
Position. B, B' , Bladder ; R, rupture. 



807, 808). Ruptures in the upper third of the vagina may originate from 
mere extension of cervical lacerations into the culs-de-sac, or they may begin in 
the vagina itself, usually the posterior fornix. These injuries, unlike those of 
the lower and middle thirds, run chiefly in a transverse direction. In the 
most serious types the vagina may be torn across — the so-called "colporrhexis." 
The vagina may also be separated from the uterus as a result of longitudinal 
stretching, which results when 
the uterus with the cervix is 
drawn upward over the present- 
ing part. This condition is seen 
at times in certain presentations, 
such as shoulder or head in nar- 
row pelves. Spontaneous rup- 
ture of the posterior cul-de-sac 
has been seen in connection with 
pendulous abdomen, congenital 
shortening and various acquired 
alterations in the vagina. In- 
troduction of the hand into the 
vagina in the performance of 
version is a very common cause 
of rupture. The same may be 
said of the application of the for- 
ceps. Injuries of the anterior 
fornix are also almost always 
artificial. 

Symptoms. — The lacerations 
are often very superficial; a 
higher degree of injury goes 
through the vaginal wall into the 
paravaginal tissue; finally, the 
laceration may extend through 
the wall of the rectum. Most of 
the tears in the inferior segment 
extend into the perineum, but 
very deep lacerations sometimes 
fail to involve the latter. A pecu- 
liar form of laceration some- 
times occurs in which the mu- 
cosa of the inferior vaginal seg- 
ment tears slightly while the 
submucous tissue is extensively 
ruptured. Under these condi- 
tions a pocket is formed in which 
the lochial secretions may col- 
lect, with the formation of ab- 
scess and fistula. We sometimes see bilateral tears opposite the junction of 
the ascending rami of the ischium and the descending rami of the pubis. Some 
of these injuries are deep enough to lay bare the periosteum. Lacerations at the 
anterior commissure between the clitoris and urethra usually bleed profusely. 
Lacerations of the middle and lower third are accompanied by hemor- 
rhage and may be followed by infection or by the formation of urinary or fecal 




Fig. 808. 



-Utero-vesical Rupture. 
Degree of Fig. 807. 



Advanced 



652 PATHOLOGICAL LABOR. 

fistulas. Hemorrhage is seldom profuse unless the tears extend into the para- 
vaginal tissue. Lacerations of the ostium vaginas extending upward by the side 
of the clitoris may provoke hemorrhages which threaten life. In extensive in- 
juries, especially in the " pocket " ruptures already described, there may be high 
fever, stagnation and putrefaction of lochia, pelvic cellulitis, and general infec- 
tion. Extensive injuries give rise to cicatricial stricture of the vagina. 

Diagnosis. — Lacerations of the lower third which are continuous with vulval 
or perineal tears are diagnosticated by stretching the ostium vaginae with the 
fingers, when the course and extent of the injury may be determined (Figs. 639 
and 640). If, with vulva and perineum intact and uterus well contracted, 
arterial blood escapes from the vagina, it is evident that a laceration exists either 
in the cervix or in the upper third of the vagina. The uterus should be pushed 
into the lesser pelvis and drawn down with volsella forceps. It is common under 
these circumstances to see a deep laceration from the cervix into the fornix 
vaginae. Transverse lacerations of the posterior cul-de-sac, which sometimes 
extend through the peritoneum, may be almost as grave in their consequences 
as rupture of the uterus. The clinical picture is much like that of the latter, and 
the diagnosis should be made with the hand in the vagina. 

Treatment. — Deep lacerations recognized soon after delivery should be su- 
tured. If the rupture forms a pocket in the submucous tissue it must be irri- 
gated with antiseptics and packed with gauze. In severe contusions the vagina 
must frequently be irrigated in such a manner that the affected surface is kept 
clear of the lochial discharge. If fistulae form, they sometimes close spontane- 
ously under daily touching with nitrate of silver. 

3. Lacerations of the Pelvic Floor. — These injuries comprise ruptures of the 
fourchette, posterior vulval commissure, perineum, lower third of the posterior and 
lateral vaginal walls, and the recto-vaginal septum. The tissues involved may 
include the integument from the anal orifice to the posterior vulval commissure, 
the mucous membrane of the vulva, vagina, and rectum, the cellular tissue, 
the sphincter ami and levatores ani muscles. 

Varieties. — These lacerations exhibit many varieties and may be classified 
in various ways. The arrangement which is taught in most text-books is, how- 
ever, only partially correct. It presents these injuries as occurring in three 
degrees, as follows: The mildest grade of rupture extends from the posterior 
vulval commissure for a variable distance into the perineal body; the second 
degree extends as far as the sphincter ani, while in the highest degree the rupture 
involves the sphincter and the recto-vaginal septum. This mode of grouping 
takes no cognizance of lacerations of the vaginal sulci, which are the most fre- 
quently occurring and the most important of all the accidents, owing to the 
participation in the rupture of the levator ani muscle. Central rupture of the 
perineum is described by most authors as an injury sui generis, as if it had no 
connection with the common varieties. It seems to me that the only way of 
classifying and naming these lacerations is that which takes cognizance of the 
precise tissues involved. Thus, ruptures of the pelvic floor are (1) lacerations, 
(2) submucuous or muscular ruptures. 

(1) Lacerations are (a) vulval (fourchette, posterior commissure); (b) vulvo- 
perineal; (c) vaginal (described under that head); (d) intraperineal (so-called 
central rupture) (vagina also involved); (e) lateral vagino-perineal (vulva in- 
volved), unilateral, bilateral; (/) postero-lateral vagino-perineal ; (g) vagino-peri- 
neo-anal or rectal; (h) perineo-rectal (extension of central rupture into rectum). 
(a) Vulval: Abrasions and superficial tears of the vulva occur in most labors. 
(Fig. 809.) In 100 consecutive cases Auvard found 81 such lesions. In 49 



MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 



653 



cases there were accompanying lacerations of the perineum. In 32 the anterior 
and lateral parts of the vulva alone were involved. Tabs are frequently seen 
at the sides of the vulva after a difficult second stage. Buttonhole tears have 



M^m 








Fig. 809. — Abrasions and Superficial 
Tears of the Vestibule and Vulva. — 
(Redrawn after Bar.) 



Fig. 810. — Abrasions and Superficial 
Lacerations of the Vestibule and 
Vulva. — (Redrawn after Bar.) 






^T % 





Fig. 811. — Lateral Vagino-perixeal 
Ruptures with Abrasions of the 
Vulva. — (Redrawn after Bar.^ 



Fig. 812. — Perforations and Lacera- 
tions of the Labia Minora and Vagi- 
nal Inlet. — (Redrawn after Bar.) 



654 PATHOLOGICAL LABOR. 

been observed in the labia minora. In rare instances — only three or four are 
on record — the urethra has been involved. Most vulval lacerations are super- 
ficial and heal readily under antiseptic treatment. Lacerations at the side of 
the clitoris may bleed profusely. The chief danger, however, is from sepsis, 
since the vulva, unlike the vagina, is the habitat of the streptococcus and other 
pathogenic germs. Fourchette: This ruptures in primiparae as a continuation 
of rupture of the base of the hymen. Posterior commissure: This is torn by 
extension of the hymen-fourchette laceration. Ruptures of the base of the 
hymen and fourchette occur practically in all first labors and are not included 
in the statistics of ruptured perineum, (b) Vulvo-perineal: In actual rupture 
of the perineum the mildest degree must involve the posterior commissure and 
extend for a variable distance into the perineal body. (See Part X.) (c) Vag- 
inal: Rupture limited to the lower third of the posterior vaginal wall is de- 
scribed under the head of lacerations of the vagina (q. v.). (Fig. 816.) (d) 
Intraperineal: This is the so-called central rupture or perforation of the peri- 
neum. (Figs. 813 and 814.) The posterior wall of the vagina is extensively 
involved. Very rarely the entire fetus passes through such an opening. (Fig. 
814.) It is a rare accident, but 75 cases being mentioned in literature. These 
ruptures may readily unite, but cases have occurred in which a permanent opening 
has resulted, (e) Lateral vagino-perineal: These represent a continuation of 
vulvo-perineal ruptures which extend into the vaginal sulci on one or both 
sides. (Fig. 811.) They are very common and produce serious results because 
the fibers of the levator ani may be included in the rent. When both sulci are 
involved a Y-shaped lesion is produced. (/) Poster o-lateral vagino-perineal: This 
is the " perineal rupture of the second degree " of most authors. It extends to 
the border of the anus without involving the latter. (Fig. 811.) (g) Vagino- 
perineo-rectal: This is the " rupture of the third degree," or complete rupture — 
a rare accident. (See Part X.) As it extends through the anus and recto- 
vaginal septum, it produces fecal incontinence. There is little or no attempt 
at spontaneous repair, (h) Perineo-rectal: A very few cases of intra-perineal 
or central rupture have extended into the rectum. 

(2) Submucous or muscular ruptures were first described by Schatz. They 
occur in patients with unusual elasticity of the skin of the perineum. When 
the latter is distended by the advancing fetus, the elastic integument readily 
yields, while the more rigid muscle is ruptured. (Figs. 815 and 816.) 

Frequency. — It is usually asserted that some injury to the perineum results 
in 30 per cent, of labors in primiparae and 10 per cent, in multiparas. Such 
figures refer to maternities, where the prophylaxis of these injuries is intelli- 
gently managed. Doubtless in miscellaneous midwifery practice, in which the 
attendants include numerous midwives and untrained physicians, the figures 
would be considerably higher. Perineal lacerations are generally admitted 
to be the most frequent of all maternal birth traumatisms. In 1200 confine- 
ments at the Mothers' and Babies' Hospital, I found that* perineal lacerations, 
requiring suture, occurred in 88 cases, or 7.33 per cent.; and in 1000 cases 
at the New York Maternity, in 211 cases, or 21.10 per cent. It is worthy of 
note that in the first series, with a frequency of 7.33 per cent., nearly all the 
1200 cases were used for clinical demonstration, students delivering the patients 
under the supervision of a hospital interne, while in the second series, with 
21.10 per cent., no clinics or demonstrations were held, nor were students 
permitted to deliver the cases. 

Etiology and Mechanism. — This is considered under prophylaxis, page 
656. The predisposing causes of perineal rupture include unusual rigidity 



MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 



655 



of the tissues, seen especially in elderly primiparae, corpulence, oedema, and 
the peculiar friability of tissue seen in certain women. Exciting causes com- 
prise rapid expulsion in normal labors, whether delivery is spontaneous or 
artificial. The birth of the suboccipito-frontal circumference of the head is 
always a menace to the integrity of the perineum in cranial and breech posi- 
tions, as is the occipito-mental in face presentation. The perineum is also 
menaced by the abrupt expulsion of the posterior shoulder in head presenta- 
tions. The mechanism of traumatisms of the pelvic floor is believed to be 
as follows: (i) When the remains of the hymen give way to the presenting part 











Fig. 



13.— Central or Intra-perineal 
Rupture. — (Lepage.) 



Fig. 



14. — Central or Intra-perineal 
Rupture. — (Lepage.) 



the laceration may extend to the fourchette, or, in a multipara, may begin in 
the latter. According to the circumstances in each case, the injury may stop 
at the fourchette or extend to a variable degree into the pelvic floor. (2) 
The rupture of the floor is simply a continuation of the vaginal laceration. (3) 
The mucous membrane is the first to yield, the tear extending into the sub- 
jacent tissue. Intraperineal or central rupture occurs, according to Budin, 
in primiparse the residue of whose hymens is extraordinarily unyielding. In 
these cases the distended posterior vaginal wall ruptures, involving the entire 
perineum in the injury. 

Diagnosis. — This is made by inspection and palpation, the parts being 
put on the stretch (Figs. 639 and 640). 



656 



PATHOLOGICAL LABOR. 



Prognosis.— Rupture of the pelvic floor is a serious accident, especially 
when the muscles are involved. The bad results may be immediate or remote. 
The former include the possibility of septic infection, which can occur if the 
recent wound is not successfully repaired. An infected lochial discharge may 
interfere with union by second intention. The ultimate results of perineal 
tears when extensive and unrepaired are as follows: The anterior wall of the 
vagina which rests upon the intact perineum sags down, dragging the uterus 
with it. The ostium vaginas becomes more patulous and allows the posterior 
wall of the vagina to prolapse. Rupture of the levator muscle also causes 





Fig. 815. — Lacerations of the Vaginal 
Sulci and Submucous or Muscular 
Rupture of the Perineum. The in- 
tegument over the perineum remains in- 
tact. — {Redrawn after Bar.) 



Fig. 816. — Submucous or Muscular Rup- 
ture of the Perineum. The integu- 
ment over the perineum remains intact. 



sagging of the pelvic floor. Incontinence of feces results from rupture into 
the rectum. 

Treatment. — Prophylaxis: Preservation of the perineum has been placed 
by some authorities as second in importance only to preservation of the lives 
of the mother and child. From this standpoint it is possible to discuss the 
entire mechanism and conduct of labor with the one aim in mind of favoring 
the perineum under all circumstances when the more weighty conditions 
do not assert themselves. This has actually been done by Krantz.* The 
factors which bear directly and indirectly upon the state of the perineum are 
numerous, but for convenience we may make three major classes : (1 ) Anomalies 
of the expulsive forces; (2) anomalies of the soft parts, — vagina and perineum; 
(3) faulty presentations and positions of the child. 

Curative treatment. (See Operations, Part X.) 

* " Die Aetiologie d. geb. Dammverletzung," Wiesbaden, 1900. 



MATERNAL DYSTOCIA IN THE PARTURIENT TRACT. 657 



IX. LABOR AFTER OPERATIONS INVOLVING THE GENITALS. 

Pregnancy and Labor after Ventrofixation and Ventrosuspension. — These 
operations have now been performed many hundred times. Up to 1896 at 
least 808 had been done in America alone.* In this series of cases at least 
one ovary was left, and pregnancy followed in 56 (nearly 7 per cent.) of the 
patients. The mortality in the fifty-six pregnancies was less than 5 per cent., 
and but one of the three deaths could be attributed to the operation. The 
percentage of pregnancies terminating in abortion was 7. In a series of foreign 
operations f comprising the results of 175 pregnancies, there was 10 per cent, 
of abortions and 2.25 of deaths. It is a matter for regret that in these joint 
statistics of 231 pregnancies no distinction is made between the older and 
more dangerous operation of fixation and the more recent and safer ventro- 
suspension. In the American series of 56 cases there were three forceps deliv- 
eries, two retained placentas, and one induced labor, for uncontrollable vomiting. 
Hence, over 11 per cent, of the pregnancies (the abortions having been sub- 
tracted from the total) were dystocic. In the series of foreign cases the 
percentage of dystocic labors was exactly 14. These percentages are of course 
unfavorable in comparison with the results of labor under ordinary circum- 
stances, and therefore some authorities J advise a careful forecast of the chances 
of dystocic births, and if such are imminent they counsel induction of labor 
at the eighth month. During the sixth month a series of examinations should 
be begun for the purpose of controlling the position of the cervix, which may 
be found to be drawn up out of the pelvis despite the apparently natural 
relations of the fundus. If the cervix is thus displaced, its anterior wall is 
said to constitute a tumor at the brim of the pelvis. According to Dickinson, I 
it is by no means easy to estimate the dimensions of this tumor. Bidone || 
once forestalled the results of ventrofixation, when delivery seemed to be im- 
possible, by performing laparotomy and dividing the adhesions which crippled 
the uterus. Judging from the favorable termination of the majority of cases 
of pregnancy following these operations, this resource of Bidone 's is indicated 
only under very exceptional circumstances. As in cases of obstructive dystocia 
in general, the issue most to be dreaded in theory is rupture of the uterus. 
Dickinson,** who has had one fatality from this accident and who performed 
Caesarean section in a subsequent case (of twin pregnancy), with a second 
fatal result, assures us that rupture of the uterus is a rare termination of these 
labors, and that but eight Caesarean sections are on record in this connection. 
In both of Dickinson's fatal cases fixation of the uterus was present, although 
in the first example the operator had attempted to perform suspension. 
Ventral fixation as pregnancy advances may possibly result in what is practically 
a ventral suspension, by the constant dragging of the ever-enlarging uterus. 
A more serious termination, however, is the occurrence of marked expansion of 
the cornua, and an exaggerated anteflexion of the anterior uterine wall. The 
cervix is drawn upward and backward, even to the sacral promontory, and 
an elongation or supravaginal hypertrophy of the cervical canal results (Fig. 
817). The internal os, then, may be found as high as the second or third lumbar 

* Gordon: "Transactions of the American Gynecological Society," 1896. 

t Noble: "Transactions of the American Gynecological Society," 1896. 

X "Amer. Jour, of Obstetrics," 1901, xliv, 40. 

§ Dorland and Noble: "Amer. Jour, of Obstetrics," 1897, p. 121. 

|| "Amer. Jour, of Obstetrics," 1901, xliv, 40. 
** "Amer. Jour, of Obstetrics," 1901, xliv, 34. 
42 



658 



PATHOLOGICAL LABOR. 



vertebra. I saw a case of this character in consultation with Dr. Nathan G. Boze- 
man of New York. The patient was at term, suffering from secondary inertia 
and exhaustion, with a dead fetus in the left scapulo-anterior position. After 
a difficult dilatation of the elongated cervical canal, I was able to seize the 




Fig. 817. — Maternal Dystocia following Anterior Fixation of the Uterus. Shoulder 
presentation, in the left scapulo-anterior position; buckling of the uterus upon itself; 
elongation of the cervical canal; manual dilatation of the cervix followed by a difficult 
version and extraction, and delivery of a dead fetus. — {Case seen by the author in 
consultation with Dr. Nathan G. Bozeman, of New York.) 



upper leg and gradually extract the child around the obstruction formed by 
the hypertrophied cervix and thickened fundus (Fig. 817). 

Labor after Vaginofixation. — Ruhl * states that severe interference with 
labor may result from the fixation of the uterus at the anterior vaginal wall. 
Nevertheless, among hundreds of cases in which this operation has been 



performed, but 9 are on record in which labor had to be terminated 
* " Monat. f. Geburts. und Gynak.," xiv, p. 477. 



by 






MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 659 

Caesarean section; most of the labors having been uneventful. Ruhl was able 
to supply notes of 71 cases of vaginofixation followed by pregnancy. In 3 
cases it was necessary to incise the anterior utero-vaginal wall, but in the others 
there were no difficulties attributable to the operation. Even in numerous 
cases in which the fundus was attached to the vagina, and in which trouble 
might have been expected, there were no complications of labor except in 
the three cases just mentioned. When the fundus is sutured to the vagina 
the former is deeply placed, the cervix has a high position and is retrodisplaced, 
the posterior uterine wall is upon the stretch, and the anterior wall is doubled 
upon itself. The fundus lies close above the symphysis. Labor under these 
circumstances pursues a peculiar course. Slight uterine contractions are 
noted days and even weeks before labor sets in, and finally the os slowly dilates. 
In these cases mechanical dilatation, as by the use of the colpeurynter, is of 
little benefit because of the unnatural position of the cervix. After prolonged 
waiting the os is sufficiently dilated for the introduction of the hand, but the 
latter can enter only in a cramped position, so that version, forceps, etc., are 
hardly practicable. Ruhl on two occasions inserted his entire hand and grasped 
a foot, but could not deliver the child. In a case in which Caesarean section 
was performed the uterus was found strongly anteflexed, literally standing 
on its head, and the posterior wall was stretched almost to the thinness of 
paper. 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 

X. UTERINE, OVARIAN, RENAL, AND PERITONEAL TUMORS. 

General Considerations. — Tumors may produce either relative or absolute 
obstruction of the birth canal. In the former case the birth of a living child 
may be possible, either unassisted or with the aid of forceps or version. If 
the presence of the tumor is recognized during the course of gestation, extir- 
pation may be possible; or if not, the pregnancy may be interrupted or ar- 
tificial premature delivery performed. If the obstruction to delivery is 
absolute at term, Caesarean section or perforation must be the indication. 
While numerous forms of benign neoplasms may be present in the pelvis, 
the vast majority are either uterine myomata or ovarian tumors. 

Uterine Myomata. — The association of these growths with pregnancy is 
not of frequent occurrence, perhaps because women thus afflicted are very 
often sterile. Hofmeier (1900) shows that the greatest fecundity occurs before 
the age of thirty-five, while myomata tend to appear after that period. When 
a woman with myoma becomes gravid, the tumor begins, as a rule, to increase 
in size. If it is located within the lesser pelvis, an incarceration of the mass 
may occur, which tends to produce a benign form of degeneration under which 
complete disappearance may result. On the other hand, the myoma may be 
displaced upward with the enlargement of the uterus, a fact which the physician 
should turn to account by a careful examination from time to time. This dis- 
placement may occur very late in pregnancy, after the operation of Caesarean 
section had been decided upon. Exceptionally the presence of these growths 
may set up peritonitis, thereby adding to the difficulties already present. As a 
rule, the presence of myoma uteri interferes little with the course of gestation. 
Again, if the tumors affect the cervix rather than the body of the uterus, 
mechanical disturbances of several kinds may occur, and it is this form which 



660 



PATHOLOGICAL LABOR. 



tends to produce the higher grades of obstructive dystocia. Although, as already 
stated, tumors in the bony pelvis often ascend and cease to obstruct labor, 
even after the latter is under way, this mobility appears to be made possible 
by a softening which they sometimes undergo during gestation. After delivery 
these tumors tend to diminish in size, corresponding to the increase noted after 
conception. They may undergo a process of complete involution, running parallel 
with that of the uterus itself. The presence of myomata during the third stage 
of labor interferes with the detachment and expulsion of the placenta, thereby 
favoring the occurrence of post-partum hemorrhage. Uterine myomata may 
undergo suppuration during the puerperal period, becoming foci of local sepsis. 
Diagnosis. — The condition may lead to several difficulties of diagnosis. 

Thus, the metrorrhagia 
from the presence of the 
tumor masks the amenor- 
rhea of gestation; the en- 
/largement of the uterus 
\ \ occurs as the result of 

\ either condition. As preg- 

nancy advances the tumor 
may soften to a remarkable 
degree and thus be over- 
v looked; if a diagnosis of 

, myoma has already been 

suggested, this seeming dis- 
appearance may lead to a 
change of opinion. 

Prognosis. — This de- 
pends entirely upon the 
size and seat of the tumor. 
Small subserous or intersti- 
tial tumors may be ignored 
in prognosis and treatment. 
Others may or may not re- 
quire extirpation during 
pregnancy. As a rule, ges- 
tation itself is undisturbed 
JpF " by the presence of the 

growths. Labor and the 
d Cervix, puerperium may not be in- 
terfered with. 

Treatment. — During 
pregnancy the management is as follows: If the size and seat of the tumor 
occasion apprehension for the welfare of the mother and child, it is better to 
perform myomectomy, either abdominal or vaginal, than to interrupt pregnancy, 
for this interruption destroys the child, is dangerous to the mother, and is with- 
out effect upon the tumor. The danger of accidentallyinducing abortion through 
the operation of myomectomy is slight. If this operation is impracticable, supra- 
vaginal amputation of the pregnant uterus should be performed. Growths which 
are dangerous chiefly from their position in the lesser pelvis should be watched 
carefully in the hope that they may ascend. We should even refuse to inter- 
fere at term, since this ascent often occurs after labor has begun. Then, if ascent 
has not occurred spontaneously, the patient should be anesthetized and placed 




Fig 8ii 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 



661 



in the lateral, abdominal, or knee-elbow position, when it will often be possible 
to press the mass into the abdominal cavity, even when it appears to be incar- 
cerated in the pelvis. If the tumor is irreducible, it is better to perform Cesa- 
rean section, even if the child is dead, because of the great difficulty in perfor- 
ating and extracting in the presence of the growth in the pelvis. 

Ovarian Tumors. — The presence of these neoplasms in the abdominal cavity 
adds to the pressure symptoms caused by the pregnant uterus, and during labor 
interferes with the force of the uterine contractions. In cases in which they 
remain in the pelvis they may cause either partial or complete obstruction 
of the birth tract. Diagnosis: The under surface of the tumor may be 
made out by the vaginal touch. If fluctuation cannot be recognized, an explora- 
tory puncture may be made. As a rule, the cervix is placed very high, and 
the presenting part of the child does not descend. Course and Prognosis: The 
complication of ovarian tumor with pregnancy is always serious. The cyst is 
liable to rupture, which event might be re- 
garded as desirable except for the danger of 
peritonitis, hemorrhage, and gangrene of 
the cyst. Treatment: Such cases should 
never be left to Nature. If the tumor is 
recognized during pregnancy, it must be 
extirpated unless very small. The same 
course is advised even during labor, when- 
ever practicable. Thus, in a typical case 
the indication would be to perform laparo- 
tomy, extirpate the growth, and terminate 
the labor by Caesarean section. This course 
cannot be pursued as a matter of routine, 
and in the majority of cases the operator 
has to be content with the attempt to push 
the tumor from the pelvis into the abdom- 
inal cavity. He must be prepared in these 
cases for the accidental rupture of the cyst ; 
and if the attempts at reposition fail, he 
should seek to diminish the size of the 
mass by tapping. If this resource also 
fails, and if the exigency of the case forbids 
extirpation of the growth, Caesarean sec- 
tion alone must be performed. 

Miscellaneous New Formations. — Other benign tumors which may cause ma- 
ternal dystocia are of rare occurrence. They comprise dermoids of the pelvic 
connective tissue; echinococci in the same location and also in the peritoneal 
cavity; floating kidney and spleen, etc. As a rule, the various cystic formations 
should be treated like ovarian tumors. Displaced organs should be replaced 
before delivery, or if they complicate labor they should be thrust out of the 
way. Hernias — umbilical, inguinal, femoral — may form an obstacle to labor 
by interfering with the proper force of intra-abdominal pressure. They should 
be reduced or held in position until after the delivery has been effected, when, 
if necessary, they may receive attention. 




Fig. S19. — Myoma of the Cervix 
which Has Been Pushed Down into 
the Vagina by the Advancing 
Head. Face Presentation. Left 

Mento-anterior. 



662 PATHOLOGICAL LABOR. 



XI. ANOMALIES OF THE MEMBRANES. 

The dystocic element in force here is connected principally with the period 
of rupture, and hence we may consider the entire subject under the following 
classification: (i) Dystocia from premature rupture; (2) dystocia from tardy 
rupture; (3) dystocia from adherent membranes. 

1. Premature Rupture. — Premature rupture is not necessarily due to any 
intrinsic peculiarity of the membranes, but to anomalous conditions elsewhere; 
i. e. , contracted pelvis, or shoulder presentation. A certain proportion is thought 
to be of endometritic origin. Early rupture of the membranes is of frequent 
occurrence, but the condition is not invariably dystocic because the amniotic 
fluid does not necessarily all escape. When such is the case, however, the 
dystocic condition known as "dry labor " develops. (Page 626.) The loss of 
the water wedge before the completion of dilatation brings the head of the 
fetus in direct contact with the cervix ; this tends to induce a tetanoid action 
of the uterus and work injury to the cervix. The latter becomes greatly 
elongated and its anterior lip often cedematous; laceration is very common. 
Compression of the fetal head causes a tendency to asphyxia and intracranial 
hemorrhage. The tetanoid action of the uterus combined with the cedematous 
cervix retards the first stage of labor and exhausts the mother. Premature 
rupture is greatly dreaded in anomalous presentations and contracted pelves, 
conditions under which it is especially prone to occur. In such cases it con- 
tributes a further element of dystocia. The form of irregular uterine action 
caused by dry birth is described under anomalies of- the expulsive forces (page 
626); the injuries of the cervix are given on page 649, and the treatment comes 
under the head of protracted first stage. (Page 628.) 

2. Tardy Rupture. — Dystocia connected with tardy rupture of membranes 
originates in anomalies of the membranes themselves, such as increased density 
or elasticity. After full dilatation there is no tendency to spontaneous rupture, 
engagement goes on, and rupture may occur in the vagina or the fetus may 
be born with its membranes intact ("born with a caul ") (Fig. 988). Dystocia 
in these cases comes from the additional work thrown upon the uterus by 
having to expel the unyielding amniotic fluid along with the fetus. This con- 
dition is remedied by simply puncturing the membranes as soon as dilatation 
is complete. 

3. Adhesions. — Another form of dystocia of membranous origin is due to 
adhesions between the membranes and the lower segment of the uterus. The 
cause is endometritis. When labor begins, the cervix fails to dilate and the 
condition may be confounded with agglutination, inertia, rigid os, etc. The 
cervix is pervious to the finger and the adhesions may be plainly felt. Although 
the uterine body may be contracting readily, the cervix remains passive. After 
a variable period the chorion gives way and dilatation begins with the amnion 
as the sole membrane of the bag of waters. In some cases the chorion does 
not give way of itself; it must then be detached by sweeping the finger around 
the inner os. (Page 629.) If this attempt fail, it is justifiable to puncture 
the bag of waters even if dilatation has not occurred, as the os will then 
dilate. 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 663 



XII. RIGIDITY OF THE INTERNAL AND EXTERNAL OS. TRISMUS 

UTERI. 

Numerous states of the cervix may be responsible for its failure to dilate 
during the first stage of labor. The various conditions which determine dystocia 
of cervical origin should be considered together, even at the risk of repetition r 
especially in regard to differential diagnosis, although some of them are not 
entitled to the designation of rigid os or cervix. The causes of cervical dys- 
tocia may be divided into (i) functional, (2) organic, and (3) constitutional or 
anatomical. 

1. Functional or Spastic Rigidity. Trismus Uteri. — Dystocia of functional 
origin is due principally to a spastic rigidity of the external os; much more 
rarely, and usually in premature births, we observe a corresponding condition 
in the internal os, more pronounced in induced than in spontaneous delivery. 
The extreme type of spastic rigidity is known as "trismus uteri." Dystocia, 
of functional character is very common, its frequency being partly due to 
the great variety of conditions under which it occurs. Etiology: Since typical 
uterine contractions coincide with the active dilatation of the cervix under 
normal conditions, anomalies of the expulsive forces may readily affect the 
action of the cervical muscles. If the uterine contractions are weak and inef- 
fective, a moderate degree of rigidity of the external os may be apparent. In 
other words, we may recognize a special type of rigidity, mild in character, due 
to inertia uteri. A second more pronounced type is the reflex. Some conditions 
on which this depends are (1) the immediate pressure of the fetal head on the 
cervix in premature rupture of the membranes with evacuation of the amniotic 
fluid; (2) the presence of a malposition of the fetus with failure of the presenting 
part to adapt itself to the cervix, the membranes having prematurely rup- 
tured; (3) pre-existent inflammatory conditions of the lower segment; (4) 
ill-advised attempts at operative interference; (5) any condition of the upper 
segment which can induce painful contractions; (6) distended bladder and rec- 
tum. Spasm of the internal os is a condition evidently little understood. Some, 
with Galabin, regard this os as capable of contracting and producing dystocia, 
but only in premature births. Doleris states that spastic rigidity of the external 
os may involve the internal os and even the whole lower segment. In addition 
to essential functional rigidity, it is highly probable that in the organic forms 
about to be described more or less functional spasm coexists. A species of 
rigidity which appears to be sui generis is that which occurs in elderly primip- 
aras. It has been termed "organic," "functional," and both combined. It has 
been proposed to distinguish this form by the names "constitutional" or "ana- 
tomical," and it will be described later. 

2. Organic Rigidity. — The numerous conditions which have been comprised 
under this head are divisible into two classes, (1) congenital and (2) acquired. 
(1) Congenital: Atresia, congenital elongation of the portio vaginalis, and con- 
ditions described as congenital atresia and stenosis are largely hypothetical. 
Complete imperforation would prevent all chance of conception. Congenital 
elongation of the portio is practically the only known congenital malformation 
of the os from the standpoint of cervical dystocia. This condition has been 
known to delay the first stage of labor and to require mechanical dilatation. 
A congenital density of the tissue of the cervix may occur in connection with 
certain cases in which a small amount of cervical endometritis has been followed 
by organic rigidity of the os. (2) Acquired: These may be divided into four 
classes: (1) Conditions which alter the consistency of the cervix; (2) conditions 



664 PATHOLOGICAL LABOR. 

which efface the os; (3) deviations of the cervix; and (4) adhesions between 
the cervix and membranes. The three last named have all been described else- 
where (pages 660, 665, 662). There remains for consideration acquired organic 
rigidity in the narrower sense of the term. Of this there are six varieties: 
(1) Traumatic or cicatricial. These are caused by operation or the use of the 
cautery. Authorities differ as to the ability of the ordinary tears of child- 
birth to produce this condition. Sloughing of the cervix should be followed 
by changes of this character. The parts are the seat of more or less 
scar tissue, while the cervical canal may contain bridles of the same. (2) 
The hypertrophic conical elongation of the cervix as seen in prolapse of the 
genitals. Such a cervix dilates slowly, but there is no further abnormality. 
(3) Inflammatory. More or less rigidity may result from cervical endometritis 
and metritis if severe or protracted. (4) Specific. Tarnier devotes consider- 
able space to syphilitic rigidity of the cervix which may occur in a variety 
of forms — the induration of a primary sore, the sclerosis which follows upon 
the unnatural development of the mucous patches in connection with that 
of the pregnant uterus; gummata; tertiary ulcers; cicatrization, and, finally, 
a peculiar type of sclerosis comparable to syphilitic stricture of the rectum, 
in which, as is well known, the lesions are non-specific, although the cause 
is clearly syphilitic (parasyphilitic sclerosis). (5) Neoplastic. Benign tumors 
of the cervix have been considered elsewhere. (6) Malignant. (See Cancer 
of the Uterus, page 667.) 

3. Constitutional or Anatomical Rigidity. — By some this condition is de- 
scribed as peculiar to primiparae and accentuated greatly in the elderly, while 
others regard it solely in connection with women past a certain age. Certain 
writers would also include here the slowly dilating cervix of premature labors. 
Doleris, however, believes that in all these cases the condition present is func- 
tional rigidity of the type due to inertia, and many others see no reason to make 
a special type of rigidity out of the behavior of the cervix in premature or primi- 
parous labors. On the other hand, since there is no obvious cause for non- 
dilatation, which is nevertheless present, some name must be given to designate 
the condition. The os resists as if organic rigidity were present, although there 
is no demonstrable lesion. We know that some primiparae. have an exaggerated 
resistance of the vulva and perineum, and the same peculiarity might exist in 
the cervix. There is no spastic action. The resistance offered is wholly passive. 
During labor in one of these cervices the os does not open and the cervix is, as a 
rule, forced downward by the pains, even as low as the vulva,. There is a ten- 
dency for the cervix to become congested and oedematous. Labor may be 
delayed indefinitely, and infection is not uncommon, the waters having drained 
away. Sometimes the cervix gives way, with the production of a longitudinal or 
circular tear. It is probable that true anatomical rigidity of the higher degrees 
is a rare and independent affection, and not a mere intensification of the slow 
but natural dilatation seen under various circumstances. 

The symptoms, diagnosis, and management of the foregoing may be con- 
sidered in common. 

Symptoms. — The os dilates slightly or not at all, so that labor cannot advance. 
If dilatation is possible, the process is very slow. The condition becomes one 
of obstructed labor in the first stage and the subject is treated under that head 
(page 626). Individual symptoms will be mentioned under diagnosis. 

Diagnosis. — Spasmodic rigidity theoretically should readily be distinguished 
from any other form, but as a matter of fact spasm may be associated with organic 
rigidity, so that the presence of the latter is not excluded. Some authorities 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 665 

recognize the presence of spasm in slow dilatation by the absence of tension in the 
bag of waters, and of the normal mucus of the cervix (Galabin), by its tender- 
ness and heat, by the hard, thin, unyielding edge of the cervix (Tarnier). Con- 
stitutional rigidity, according to Tarnier, differs from the spastic type. In the 
former the os is thick, firm, and insensitive. When a physician is confronted 
by non-dilatation, he should exclude all possibility of such conditions as deviation 
and occlusion and of adhesions between cervix and membranes. He then has 
to distinguish between (i) functional, (2) organic, and (3) constitutional rigidity. 
Owing to differences in the conception of these conditions by different authori- 
ties, it is hardly possible to lay down rules for diagnosis which will be in har- 
mony with the teachings of all. It is of vital importance to distinguish between 
mere slowness of dilatation and organic rigidity, etc. ; in other words, between 
cases for intervention and for non-intervention. 

Treatment. — Spastic rigidity: The tendency of this condition is gradually to 
disappear; dilatation being finally established. Serious accidents are rare. A 
certain amount of expectancy is indicated in conjunction with antispasmodics, 
including belladonna ointment and cocain applied to the cervix, warm vaginal 
irrigations, chloral or opiates by the rectum, and, if the preceding fail, the in- 
halation of chloroform. Finally, if everything has failed, spasmodic ridigity must 
be treated like other forms by multiple incisions. The preceding summary of 
treatment does not include any causal indications; it is, of course, understood 
that causal elements, if amenable to removal, will be so dealt with before other 
treatment is instituted. If the causes cannot be reached, the symptom must 
be treated directly as above. Congenital organic rigidity: After a due interval 
of expectancy, say four or five hours, artificial dilatation should be begun with 
the finger or instrumental dilators and finished with the use of the hydrostatic 
bag or by bimanual dilatation. (See Operations, Part X.) Acquired organic 
rigidity: The management of these conditions and of the so-called anatomical 
ridigity may be described together, since they are practically the same. There 
is a likelihood that all these forms of organic rigidity will be accompanied by 
a certain amount of functional spasm, hence some good might be accomplished 
by applying the treatment already indicated for spastic rigidity while awaiting 
dilatation. When intervention is proved to be necessary, dilatation should be 
attempted; and if this fails, incisions are indicated. (See Operations, Part X.) 



XIII. DEVIATION OR MALPOSITION OF THE CERVIX. 

In this condition the cervix may occupy either the anterior or posterior 
fornix or may be displaced laterally after the same fashion (Figs. 820 and 821). 
Etiology : The common but not sole cause of this condition is obliquity of the 
entire uterus. The same effect is produced, however, by overdevelopment of 
some portion of the inferior segment during the latter part of pregnancy. These 
may both coexist in the same uterus. Backward deviation is the more frequent 
clinical variety (Fig. 820). It is due either to anteversion or to overdevelopment 
of the anterior portion of the lower segment.* This form of deviation is very 
common (Fig. 820). Anterior and lateral deviations are produced in a similar 
manner, but are of much more rare occurrence (Fig. 821). Symptoms: As 
in all dystocic anomalies of the cervix, most of our information is obtained 
from touch ; confirmed in certain cases by the result of palpation of the uterus 
through the abdominal wall. The vaginal touch, which should always take 

♦Sacciform dilatation of the anterior portion of the lower uterine segment; compare 
page 467. 



666 



PATHOLOGICAL LABOR. 




ETVDC 



account of the culs-de-sac, finds one effaced and the other of undue depth. In 
backward deviation the fetal head is often found engaged and almost upon the 
pelvic floor. The cervix looks directly backward upon the sacrum, at a height 
which varies in individual cases, and which may attain the promontory. It may 
be difficult in the latter case to feel the os at all (Fig. 820). In anterior deviation 

the conditions are reversed. The os 
looks toward the upper part of the 
symphysis, and it may be impos- 
sible to reach it with the finger, un- 
less the patient is first placed in the 
genupectoral position. (See Pos- 
ture, Part X.) Analogous symp- 
toms are present in lateral de- 
viation. Diagnosis : If the prac- 
titioner cannot locate the os, he 
may conclude erroneously that 
he is dealing with imp erf ora- 
tion of the cervix, or that the 
latter has become completely ef- 
faced by dilatation. It has hap- 
pened that the inexperienced have 
sought to apply forceps under the 
latter misapprehension. In order 
to make a differential diagnosis it 
is sometimes justifiable to rupture 
the membranes. I urge that the 
patient be chloroformed and a 
manual exploration made. Prog- 
nosis : Generally deviations give an 
unfavorable prognosis, which varies 
with the degree of the complica- 
tion. In the milder cases spon- 
taneous restitution may occur as 
labor advances. In the more severe 
types all the phenomena of ob- 
structed labor may be developed. 
Treatment : After a period of wait- 
ing for nature to correct the devia- 
tion, an attempt should be made 
to tilt the cervix into its proper axis 
by the finger in the vagina and 
hooked into the os, choosing the 
time when a pain is present. If 
this succeeds, the position of the 
cervix should be tested during sub- 
sequent pains. If it fails, as is fre- 
quently the case in anterior deviation, it may be necessary to open the os me- 
chanically and to extract the child, alive or dead. 



Fig. 820. — Backward' Deviation or Malposi- 
tion of the Os. Sacciform dilatation of the 
anterior portion of the lower uterine segment. 
Of frequent occurrence. 



Cetvi* 




Fig. 



821. — Anterior 
tion op the os. 



Deviation or Malposi- 
A Rare Anomaly. 



XIV. 

This condition— 
of the external os — 



OCCLUSION OF THE EXTERNAL OS. 

■also known as conglutination, agglutination, or obliteration 
can occur only after impregnation has taken place. How- 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 667 

ever, there is probably an incomplete degree of this condition which might 
permit the entrance of spermatozoids into the uterus. Etiology : Occlusion of 
the os comprises several types. In the simplest form the os is agglutinated 
with inspissated mucus. A more complex variety represents obliteration from 
fibrous adhesions. The actual cause of occlusion, or at least of the type of 
fibrous adhesion, is traumatism, the healing of old lacerations, the results of cau- 
terization or inflammation. A predisposition may be present, such as congenital 
narrowing of the cervix. Occlusion occurs more frequently in multigravidae. 
Symptoms and Diagnosis : There are hardly any symptoms in the ordinary sense 
of the word. The imperforate condition is recognized at the onset of labor, 
and has then been mistaken for complete dilatation. The closed os is some- 
times recognized and located by the presence of a slight prominence or depression. 
A valuable symptom is the dryness of the vagina from the absence of cervical 
secretion. Diagnosis can be made only after rigidly excluding other dystocic 
anomalies of the cervix. It is often impossible to distinguish between the two 
principal forms of obliteration. Prognosis : The os may open spontaneously, 
especially in the mucus agglutination; otherwise we may look forward to the 
various phenomena of obstructed labor. Treatment : The closed os must be 
reopened, if possible, by the finger, using the nail. This is easy with mucus agglu- 
tination or incomplete fibrous occlusion. In two cases of complete occlusion 
I have reopened the os with blunt scissors during labor. In one case it was 
necessary to dilate the opening manually. In the higher degrees of the fibrous 
type it may be necessary to perform vaginal Cassarean section. (See Operations, 
Part X.) In intermediate grades it may suffice to incise the site of the os in 
different directions with the scissors or bistoury and to apply the forceps. 



XV. CANCER OF THE UTERUS. 

As a general rule, if a woman with uterine cancer becomes pregnant, the 
disease is aggravated. In some 15 per cent, of cases the pregnancies are inter- 
rupted, and in the remainder at least a third of the children are still-born even 
at term, the proportion being much larger in premature delivery. Prolonged 
pregnancy is not uncommon in women with uterine cancer. Spontaneous 
delivery is possible when much of the cervix remains intact, and even when it 
is largely replaced by cancerous tissue, provided the latter is yielding. The 
softening of the affected tissue, however pernicious in itself, may enable the 
uterus to expel its contents. If the fetus cannot pass the obstruction a delayed 
labor results, and cases are on record in which the women thus afflicted have 
been in labor for over a week. Under these circumstances maternal death from 
exhaustion, or death and putrefaction of the fetus, or general maternal septi- 
cemia may occur. Another possibility is rupture of the uterus. If delivery 
results without the occurrence of these accidents, the patient is doomed to pass 
into the cancerous cachexia. The recognition of cancer of the uterus should 
not be difficult. If some doubt exists, a piece of the cervix should be excised 
and examined microscopically. The presence of cancer sometimes obscures 
the diagnosis of early pregnancy. Treatment : If the patient is seen during the 
course of the pregnancy, an attempt may be made to let the case go on to term, 
and treat the woman with anodynes, hemostatics, tonics, etc. Such a course 
should be elected only at the request of the patient and under peculiar circum- 
stances, such as the desire for an heir. To extend this line of treatment it would 
also be rational to perform a palliative operation upon the cancer. In the 
majority of cases the natural course to pursue would be to interrupt the preg- 



668 



PATHOLOGICAL LABOR. 



nancy after the child becomes viable, or to perform a Caesarean or Porro-Caesarean 
operation, or hysterectomy. Therapeutic abortion is strictly contraindicated 
in these cases. (See Part X.) These radical measures, however, are not always 
indicated or applicable, and if the obstetrician finds himself in the presence of 
a case of labor in a woman with uterine cancer, when the immediate indication 
is to oppose the rigidity of the os, the proper course to pursue is mechanical 
dilatation or incision, the latter being full of danger to the patient. As these 
measures may be insufficient, it is permitted to perform a rapid ablation of the 
cancerous cervix and to deliver the child with the aid of the forceps or ver- 
sion ; or in case of death of the fetus, some form of embryotomy is the indication. 
Cassarean section alone is the indication of necessity when the cancer has ex- 
tended from the uterus to the vagina or has become inoperable. A total 
hysterectomy should be performed when the cancer is technically operable. 




XVI. RIGIDITY AND ATRESIA OF VAGINA AND VULVA. 

Obstruction to labor arising within the vagina may be either (i) functional 
or (2) structural. The former consists in the spasmodic condition known as 
vaginismus. 

'^1. Vaginismus. — Vaginismus is almost peculiar to first labors. If it is of 
high degree, the first indication is to resort to chloroform narcosis. If by this 

means the spasm is not overcome, 
then manual dilatation or deep inci- 
sion should be practised, with subse- 
quent application of the forceps in 
obstinate cases. The spasmodic con- 
dition of the pelvic floor may attain 
such a high degree that delivery of a 
living child is impossible. 

2. There are a number of struc- 
tural alterations of the vagina which 
cause dystocia. They may be divided 
into (1) congenital and (2) acquired. 

(1) Congenital Affections com- 
prise (a) simple narrowness or small- 
ness of the passage, (b) atresia, (c) 
septa, and (d) abnormal terminations. (a) Small vagina: This is not de- 
scribed by most authors. In Tarnier and Budin's great work * considerable 
space is given to it. Every gynecologist and obstetrician knows that some 
vaginae are unnaturally small, and while the pregnant state softens the tissue 
and makes it more distensible, such vaginae have a special tendency to lacera- 
tion during labor, (b) Atresia (Fig. 822): This term should be used to 
denote congenital imperforation which may be complete or partial. It is of 
rare occurrence in comparison with cicatricial stricture — a condition which 
it resembles. It exhibits every variation in regard to the length of the 
constricted portion and the degree of imperforation. From the standpoint 
of olystocia, atresia and cicatricial stricture may be considered together (see 
the latter), (c) Septa: The vagina may be divided into compartments by 
septa, longitudinal and transverse. Longitudinal septa represent the abortive 
vagina duplex. They form large "bridles" between the anterior and posterior 

* Paris, 1900. 



Fig. 822. — Atresia of the Vagina. 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 669 

walls and almost inevitably obstruct labor and bring about their own rupture. 
The fetus has sometimes been strangled by one of these "bridles " getting about 
its neck. Transverse septa may be multiple. They should not be confounded 
with atresia in which the narrowed area has length as well as breadth, for the 
transverse septa are mere diaphragms containing openings of various sizes. 
The opening in one of these high up in the vagina may be taken for a partially 
open os. Such a mistake could hardly occur if the physician always feels 
for the culs-de-sac. Transverse septa offer more or less resistance to labor. 
For convenience of description the septa will be considered in their dystocic 
aspects with atresia and cicatricial stenosis. Abnormal terminations: In the 
absence of external genitals the vagina has been known to empty into the 
urethra or rectum. Impregnation has actually occurred in both abnormal 
openings. Children have been born through the anus, and have even been 
delivered through the latter with forceps.* 

(2) Acquired Affections maybe grouped under the title cicatricial stric- 
ture, a term which fits them and which agrees with the nomenclature of other 
organs of tubular structure (rectum, esophagus). It is a mistake to use the 
word atresia in this connection. Cicatricial stricture of the vagina: This is due 
either to the results of traumatism or to local infection. In either case loss of sub- 
stance occurs by sloughing, ulceration, or healing by second intention. The re- 
sulting scar produces a constriction in some portion of the organ. The com- 
monest source of traumatic stricture is child-birth, which may operate in several 
ways; thus, impaction of the fetal head in the vagina may end in sloughing, so 
that a vesico- vaginal or recto-vaginal fistula may develop with the stricture. 
Again, extensive laceration of the vagina, such as results from improper use 
of the forceps, may lead to similar results. Stricture is also due to infective 
disease. 

General Consideration of Vaginal Atresia, Transverse Septa, and Cicatricial 
Stricture. — These three conditions — the two former congenital, the last ac- 
quired — represent collectively the atresia of text-books, and as far as obstetrical 
practice is concerned they may be considered together. Such a study has 
been made by Maher,t who found records of over 200 labors with such com- 
plications. He found the most common form to be a thin transverse septum 
situated midway in the vagina, having openings of varying sizes. In one-half 
of all the cases the obstruction was in the middle of the vagina, while the 
remainder were divided equally between the upper and lower thirds. The ob- 
structions may exhibit very different behavior during labor according to their 
size and consistency. They may stretch and allow the fetus to pass, may 
lacerate, or oppose such resistance to the passage of the fetus that something 
above the obstruction yields. Thus, ruptures of the uterus and of the recto- 
vaginal walls have occurred under these circumstances. The mortality in labor 
with vaginal obstruction is high for the child and considerable for the mother; 
Maher's figures are 41 and 13 per cent, respectively (Fig. 822). 

Treatment. — In the majority of cases spontaneous delivery is possible. 
Each case must be managed in accordance with the character of the obstruction. 
Attempts at dilatation will probably induce labor, hence they should not be 
employed before term unless premature delivery is desired. The use of hydro- 
static bags, digital dilatation, and shallow radiating incisions is justifiable 
to assist nature. Dilatation must be complete before the forceps is applied. 
After delivery the constricted point should not be allowed to close again; daily 

*Tarnier and Budin, Edition 1900, Paris. 

t "Virginia Medical Semi-monthly," 1897, 11, 176. 



670 



PATHOLOGICAL LABOR. 



irrigation and dilatation should be practised. When the obstruction is un- 
yielding or when vesico- vaginal fistula coexists, Caesarean section is indicated; 
but if the obstruction is such that the lochia could not escape by the vagina, 
the Porro operation is to be preferred. 

Rigidity of the Vulva ; Persistent Hymen. — The vulva may exhibit a narrow- 
ness or rigidity as a whole which is either overcome in time by the act of labor 
or leads to multiple lacerations. Unnatural rigidity of the perineum is con- 
sidered under the head of the management of this structure during labor. (Page 
532.) Aside from the vulva proper, resistance may be encountered from the 
hymen, naturally in primiparse and only when some anomaly of formation 
is present. As a rule, the various types of persistent hymen give way under 
the pressure of the child's head, but exceptions occur in which labor has actually 
been obstructed by this structure, such a state of affairs having been confounded 
with vaginismus. Such resistance has been offered in these cases that a central 
laceration of the perineum has occurred through which the child was born. 
The treatment of resistant hymen is simple, consisting in gradual digital dilata- 
tion or in multiple incisions. 

Obstructed Labor due to the Levator Ani. — (1) Occasionally instances occur in 
which a well-flexed head rotates at the pelvic floor, bringing the sagittal suture 
into the antero-posterior diameter of the outlet. Then, in spite of strong 
uterine contractions and an elastic pelvic floor, no advance occurs. In these 
cases the contraction of the levator ani simultaneously with the abdominal 
muscles (voluntary forces) offers just enough resistance to hold back the head. 
Moderate traction of a few pounds with the forceps will be sufficient to 

exhaust and overdistend the fibers of the 
muscle, and overcome the obstruction. 
(2) There are certain cases in which dan- 
gerous obstruction occurs in cases of per- 
manent hypertrophy and shortening of the 
levator; sufficient to necessitate cranio- 
tomy. 




XVII. VAGINAL AND VULVAL THROM- 
BOSIS. HEMATOMA AND OEDEMA. 

The conditions known as puerperal 
hematoma and thrombosis are occasionally 
present before the birth of the child, and 
under these circumstances, if sufficiently 
large, may constitute an obstruction to the 
presenting part (Fig. 824). This accident 
has a special significance in twin pregnan- 
cies, for while it may not occur sufficiently 
early to obstruct the first child, it may in- 
terfere with the birth of the second. Treat- 
ment: If the birth of the child is actually 
obstructed or if rupture of the tumor is 
threatened, the usual practice is to per- 
form incision and extract the child as soon 
as possible, after which hemostasis is indicated. (Edema of the vulva and 
vagina may precede labor, in which case it is due to renal or cardiac disease; 
or it may be the result of labor itself in conditions of impaction of the head in 



Fig. 823. — Pedunculated Superficial 
Thrombus of the Vagina. A, 
Turnpr drawn to left. 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 671 

the vagina. (Fig. 824.) The oedematous tissues are very vulnerable and prone 
to gangrene. The indication would ordinarily be incision, but the liability to 




Fig. 824. — Fibroid Tumor of the Right Labium Majus Resembling a Thrombus. 

septic accidents is a contraindication save when intervention is absolutely neces- 
sary. When a rupture at the vulval outlet is threatened, episiotomy may be 
performed under strict asepsis. 



XVIII. DISTENDED BLADDER AND RECTUM. CYSTOCELE, RECTO- 
CELE, VESICAL CALCULUS. 

Distended Bladder. — The subject of retention during pregnancy is considered 
on. (Page 360.) The condition is often encountered during labor, because the 
presenting part may, during its descent, press upon the neck of the bladder. 
As the cervix dilates, the summit of the bladder ascends into the abdomen. 
Abdominal palpation will therefore readily reveal the presence of the fluctuating 
mass in front of the uterus. The urine collects in the upper part of the bladder 
and impairs the efficacy of uterine contractions. An elastic male catheter 
will probably be required to reach the urine. Owing to the displacement of 
the meatus and urethra, considerable difficulty may be encountered in entering 
the bladder. It may even be necessary to push back the advancing head in 
order to make way for the passage of the instrument (Figs. 825 and 826). 

Fecal Accumulations. — The extreme type of retention of feces known as 
coprostasis, in which ordinary resources are insufficient for the evacuation 
of the bowel, constitutes a serious mechanical obstacle to delivery and may 
lead to grave consequences (Fig. 827). Such a condition is of very rare 
occurrence, for Tarnier * saw but one case. One would expect coprostasis 
to depend, in these cases, upon some malformation of the rectum, and such a 
coincidence is known to have occurred. These fecal accumulations obstructing 
a portion of the pelvic cavity must have the same dystocic effect upon labor as 
a contracted pelvis; they prevent engagement of the head and lead to faulty 
positions. Owing to the degree of hardness of the feces, removal can hardly 
be effected save by extracting them piecemeal with the finger or a scoop. 

Cystocele. — A large cystocele which produces inversion of the vagina neces- 
* Tarnier and Budin, vol. ill, p. 488. 



672 



PATHOLOGICAL LABOR. 



sarily causes a variety of stenosis of that portion of the birth tract. Such 
a condition may be due to vesical calculus (page 672). An ordinary cystocele 
may be remedied for the time being by evacuating the bladder with a catheter 




Fig. 825. — Distended Bladder During 
Labor. 



Fig. S26. — Abdomen Seen in Fig. 825, 

AFTER THE USE OF THE CATHETER. 



so bent as to reach the interior of the pouch. In cases of obstructed labor 
the prolonged compression of the vagina against the symphysis may result 
in necrosis and fistula. 

Rectocele. — This condition, due to prolapse of the vaginal wall, is very 
rarely encountered during labor. When present, the 
tumor may contain either the rectum or a portion of 
the intestines (vaginal enterocele). The diagnosis is 
made by digital exploration of the rectum. Recto- 
cele is not a formidable complication of labor and 
the danger of impaction and pressure accidents is 
not great. An enema should be given, after which 
the prolapsed vaginal wall should be replaced until 
the presenting part has passed the obstruction. (For 
consideration of enterocele, see page 672.) 

Vesical Calculus. — Stone in the bladder very 
rarely complicates pregnancy. Cases have, how- 
ever, been recorded in which calculi have obstructed 
labor either by causing vaginal cystocele or through 
impaction at the pubis. In any case of obstruction 
of the vagina the possibility of calculus should be 
excluded by passing a vesical sound. The stone 
must be removed from the region of the birth tract 
by placing the woman in the modified latero-prone 
(See Part X.) If this is impossible, vaginal lithotomy 
must be performed; the wound cannot be closed, however, until after de- 
livery. If a small calculus could become impacted in such a way as to impede 
labor, it should be possible to extract it through the urethra after previous 
dilatation. 




Fig. 827. — Distended Rec- 
tum Obstructing Labor. 
— {From W. C. Lusk's 
frozen section.) 

or knee-elbow position. 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 673 



XIX. FRACTURES OF THE PELVIS. 

In a pelvis which is greatly contracted the innominate bones may sometimes 
be fractured by instrumental delivery. This is inexcusable, for with such a 
pelvis forcible instrumental delivery is contraindicated, a safer treatment 
being some major operative procedure. On the other hand, rachitis or some 
other pathological process may render the bone so fragile that it will break 
during an instrumental delivery through no fault of the obstetrician. In certain 
cases, especially of elderly primiparae, the coccyx is broken by the passage 
of the fetal head. The condition of coccygodynia follows. This is most painful, 
and often demands subsequent removal of the broken piece (Figs. 869, 870, 
871). 

XX. DIASTASIS OF THE PELVIC JOINTS. 

Etiology: This condition is the result of the natural traumatism of labor 
and may affect the symphysis or one of the sacro-iliac jo nts. All three of 
the interpelvic articulations may be involved at the same time. A general 
predisposition to this is furnished by the relaxation which the pelvic joints 
undergo during pregnancy. Multiparas are predisposed by reason of relaxation 
from repeated pregnancies. Pelvic deformity constitutes a strong predis- 
position; so do unusual size of the fetus, disease of the joints, etc. A special 
class of cases is due to the use of the forceps. In some cases the mechanism 
of the injury is obscure, none of the preceding factors having aided in its pro- 
duction. This accident occurs with considerable frequency, especially in 
osteomalacic, generally contracted, and funnel-shaped pelves The joint most 
frequently ruptured is the symphysis. Symptoms : Unless the patient happens 
to be under the influence of an anesthetic, she usually feels "something give 
way " at the time of the accident. The limbs are seen to be rotated outward 
and are immovable. Pain, both spontaneous and induced, is usually present 
over the affected joint. When the symphysis ruptures, the vagina is usually 
lacerated, and the finger can recognize the injury by palpation. The prognosis 
is good as a rule. The treatment of ruptured symphysis corresponds to the 
after-treatment of symphyseotomy. The pelvis should be immobilized by 
strips of adhesive plaster or plaster-of-Paris and the patient should remain 
in bed four or five weeks before attempting to walk. 



XXI. PELVIC DEFORMITY. 

Definition. — A deviation in size, shape, or mobility from the normal type, 
sufficient to cause unfavorable symptoms during pregnancy and labor. The 
larger part of these abnormal forms are contractions full of danger for both 
mother and child, and often demand instrumental delivery. The deformity 
may exist in any one or all of the diameters, the most frequent and most serious 
being those which affect the pelvic inlet. Besides mechanical obstruction in 
pelvic deformity, the physician often has to deal with unfavorable mechanisms 
of labor caused by abnormal posture, position, or presentation. 

Frequency. — The frequency of pelvic contraction in native-born American 
women has been estimated at 2 per cent., and among foreign-born women 
at 6 per cent.* It is, however, probable that its frequency in American 
women, especially among the poorer classes and in the large cities, has 

* "Trans. Amer. Gyn. Soc," 1890. 
43 



674 PATHOLOGICAL LABOR. 

been underestimated. According to Winckel, pelvic contraction occurs in from 10 
to 15 per cent, of women, but it is sufficiently marked to cause symptoms in only 
5 per cent. Contracted pelves are believed to be rarer in America than abroad. 
However, Williams states that they are nearly as common in Baltimore as on 
the continent of Europe. He found that from 12 to 15 per cent, of women show 
them, but most of these were not marked enough to impede labor. Reliable 
statistics, however, are generally wanting; and it must happen that the 
lesser degrees of pelvic deformity pass unnoticed, particularly when no syste- 
matic measurements are made, and when the attention of the accoucheur is 
directed to the measurements of the various pelvic deformities only by some 
actual obstruction to the passage of the child. It has been only in recent years 
that the subject of pelvimetry has been given the place it deserves in conserva- 
tive obstetrics. The regular and routine adoption of the examination of preg- 
nancy (seepage 152), including pelvimetry, will prove to any one the frequency 
of contracted pelves. Then, and only then, will the real cause of many anomalies 
in labor be apparent, such as malpresentations and malpositions, prolonged 
labor and uterine inertia; and the premature induction of labor, the use of the 
forceps, of version, symphyseotomy, and cranioclast will not be empirical, but 
will be employed for a rational and sufficient cause. In the last ten years the 
statement has frequently been made to the author by graduates attending his 
lectures and clinics, that in several years' practice they have never observed a 
single case of deformed pelvis, but their ratio of difficult forceps, versions, 
perforations, and even vesicovaginal fistulas was fully up to the average. 

My conclusions from a critical study of 1200 consecutive hospital cases are 
as follows *: (1) Of 1200 consecutive cases measured, 499, or 41.58 per cent., 
were American-born women; 215, or 17.91 per cent., Irish; 130, or 10.83 per 
cent., Russian; 105, or 8.75 per cent., German; 30, or 2.50 per cent., black, 
etc. (2) Contracted pelves occurred in 44 cases, once in 27.27 cases, or in 
3.66 per cent. Generally contracted pelves occurred in 30 cases, once in 40 
cases, or 2.50 per cent. Flattened pelves occurred in 14 cases, once in 85.71 
cases, or 1.16 per cent. No irregular forms of contraction were observed. (3) 
Twenty, or 45-45 per cent., of my cases of pelvic contraction were among Amer- 
ican-born women, and deformity occurred once in 24.95 °f these cases, or in 4 
per cent. (4) Three, or 6.81 per cent., of the contracted pelves were among 
black women, and deformity occurred once in 10 of these cases, or in 10 per cent. 

(5) My material gives a frequency of contracted pelves (1200 cases, 3.66 per 
cent.) midway between the conclusions of Williams (Baltimore, 1000 cases, 
13. 1 per cent.); Crossen (St. Louis, 8po cases, 7 per cent.); Reynolds (Boston, 
2127 cases, 1. 13 per cent.); and Flint (New York, 10,223 cases, !-4 2 per cent.). 

(6) My statistics — 3.66 per cent, of contractions in 1200 cases — differ from those 
of England (F. Barnes, f of London, 38,065 cases, 0.5 per cent.); of France, 5 to 
2 1. 1 1 per cent. J; Germany, \ 9 to 9 per cent.; Switzerland, 8 to 16 per cent.; 
Austria-Hungary, || 2.44 to 7.8 per cent.; Russia,** 1.2 to 5.1 per cent.; Italy, ft 
18.13 per cent.; Holland, §g 3.51 per cent. (7) Special or irregular forms of 
pelvic ^ contraction, as osteomalacia, obliquely contracted, coxalgic, double 
coxalgic, spondylolisthetic and kyphotic, fractured pelvis, are uncommon in this 

* "Pelvic Deformity in New York City," "Trans. Amer. Gyn. Soc.," 1902. 

t International Gynecological Congress at Geneva, 1896 (reported in "Centralbl. f. 
Gynak. ). 

% Fochier, Pinard: Loc. cit. § Loc. cit. || Pawlik: Loc. cit. 

** Hugenberger: "Petersburg, med. Wochen.," 1872, in. 

tt Pestalozza: Geneva Congress, 1896. §§ Treub: Geneva Congress, 1896. 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 675 

country. (8) The generally contracted pelvis is the deformity most frequently 
met with in New York. I found twice as many generally contracted as flat- 
tened pelves in my material (30.14). Williams found practically the same 
condition in Baltimore (79.45). (9) Records kept of private and consultation 
cases in New York over a period of ten years show a somewhat higher percentage 
than the results obtained from the 1200 hospital cases — namely, about 5 per 
cent, for all deformities ; the generally contracted pelvis being twice as frequent 
as the flattened. The frequency seems to vary in different countries. The 
Saxon pelves are most often contracted, which explains why Zweifel has per- 
formed ninety Caesarean sections. They are common enough to explain why 
the second stage often lasts four or five hours, why face presentations and other 
anomalies are numerous. Deformed pelves are frequent enough anywhere 
to demand that the physician be familiar with the different varieties, and also 
that he be versed in the art of pelvimetry. Schauta's estimate is twenty per 
cent, in Austria. There are numerous geographical variations which do not 
yet admit of a definite explanation. Among the native American women to- 
day the rachitic pelvis is very infrequent, the most common types being the 
generally contracted and those following spinal deformity. 

General Etiology and Development. — The etiological factors which may be 
considered as producing deformed pelves are: (1) Defective development; (2) 
disease of the pelvic bones; (3) irregularities in the junction of the pelvic bones; 
(4) disease of those parts of the skeleton which are carried by the pelvis; (5) 
disease of those parts of the skeleton which carry the body-weight. (See Classi- 
fication, page 675.) The normal adult pelvis is the complicated outcome of a 
combination of various factors. (See The Passages, page 440, Part IV.) 

Classification and Description of Different Varieties. — Classification has been 
many times attempted, but with most unsatisfactory results. Different bases 
of classification have been taken, — e. g., the causes or effects, — but the variations 
are so numerous that the simplest and most scientific arrangement is based 
on the location and character of the deformity. The classification I adopt 
is practically Schauta's. 

(A) Anomalies of the Pelvis as a Result of Defective Development. — I. Generally 
symmetrically contracted, non-rachitic pelvis, justo-minor or small round 
pelvis: (1) The infantile type; (2) the masculine or strong type; (3) the dwarf 
type. II. Simple flat, non-rachitic pelvis. III. Generally contracted flat, 
non-rachitic pelvis. IV. Narrow, funnel-shaped pelvis. Fetal or "lying- 
down" pelvis. V. Imperfect development of one sacral ala (Naegele pelvis). 
VI. Imperfect development of both sacral alas (Robert pelvis). VII. Gener- 
ally equally enlarged pelvis, justo-major pelvis. VIII. Split pelvis. 

(B) Anomalies of the Pelvis as a Result of Disease of the Pelvic Bones. — I. 
Rachitis. II. Osteomalacia. III. New growths. IV. Fracture. V. Atrophy, 
caries, necrosis. 

(C) Anomalies in the Junction of the Pelvic Bones. — I. Synostosis at the 
symphysis. II. Synostosis at one or both sacro-iliac joints. III. Synostosis 
at the sacro-coccygeal joint. IV. Exaggerated motion or separation of the 
pelvic joints. 

(D) Anomalies of the Pelvis due to Disease of those Parts of the Skeleton which 
are Carried by the Pelvis. — I. Spondylolisthesis. II. Kyphosis. III. Skoliosis. 
IV. Kypho-skoliosis. V. Assimilation. VI. Lordosis. 

(E) Anomalies of the Pelvis due to Disease of the W eight-bearing Parts of the 
Skeleton. — I. Coxitis. II. Luxation of the head of one femur. III. Luxation 
of the heads of both femora. IV. Unilateral or bilateral club-foot. V. The 
absence or deformitv of one or both lower extremities. 



676 



PATHOLOGICAL LABOR. 



A. ANOMALIES OF THE PELVIS THE RESULT OF FAULTY DEVELOPMENT. 

I. Generally Symmetrically Contracted, Non-rachitic Pelvis. Pelvis ^qua- 
biliter Justo-minor, or Small Round Pelvis (Figs. 828, 831).— In the generally 
contracted pelvis the female shape is preserved but the size is diminished. 
Under this heading are grouped three sub -varieties. (1) The infantile or 
juvenile type, the bones of which are delicate and small; (2) the masculine 
type, strong pelvis, the bones of which are strong and large; (3) the dwarf 
type, which is extremely small, and whose bones, like those of the infant 

pelvis, are connected by cartilaginous instead 
of bony union (Fig. 830). 

The divisions between the innominate 
bones are distinct, as well as those between 
the vertebrae of the sacrum. In this form of 
pelvis all of the diameters have their normal 
relations, but the measurements of the entire 
pelvis are less than normal. This pelvis 
merges very gradually into other forms, as 
the generally contracted flat, the simple flat, 
and the transversely contracted pelvis. 

Frequency and Etiology. — This type of 
deformity is often found, particularly in the 
class frequenting the free hospitals and dis- 
pensaries. It is the most frequent type in 
America. I found it in 2.50 per cent, of my 
cases. These women have been born to 
hard work and unhealthy environment. 
However, this malformation is sometimes 
met with in those who are otherwise well 
formed. 

Clinical Characteristics. — The side-to-side 
concavity of the sacrum is increased; the 
sacral promontory is pushed upward, but is 
not prominent. While the posterior superior 
iliac spines are further apart than normal, 
the iliac crests and spines are closer together. 
The transverse diameters are decreased; the 
conjugate of the superior strait is shorter 
than normal; the side walls of the pelvis can 
be so easily felt that it is not uncommon for 
the finger to be able to follow the ilio- 
pectineal line. This form of pelvis is not, 
strictly speaking, a copy of the normal adult 
pelvis in small dimensions, for it has some of the characteristics of the infan- 
tile pelvis. As a rule, women with the generally contracted pelvis are short 
in stature and slender, but there are exceptions. In the forms of the generally 
contracted pelvis most commonly seen the contraction is usually slight. In 
certain instances the pelvic outlet is contracted transversely. The dwarf 
variety is most unusual, and is found only in dwarfs. 

Diagnosis. — The generally contracted pelvis can be easily differentiated from 
any other deformed type — the rachitic, for example — when it is remembered 
that the measurements, although less than normal, are symmetrically so. 




Fig. 828. — Generally Symmetri- 
cally, Non-rachitic, Contrac- 
ted Pelvis. Justo-minor or 
Small Round Pelvis. 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 



677 



There is one possible exception only — the external conjugate diameter; this, 
on account of the peculiarities of the sacrum, which is not situated so anteriorly 
as the normal, may be longer than usual. Another important measurement 
is that of the pelvic circumference, which is always much less than normal. 
The internal examination should be carefully made, especially the estimation 
of the transverse diameters. 

Prognosis. — Difficulty begins with the onset of labor and increases with 
its progress. The head is overnexed with a consequent prominence of 
the posterior fontanelle, while the sagittal suture lies commonly in an oblique 

diameter (Fig. 647). Descent is slow, but 
there is rarely the lateral obliquity, which is 
seen in flat pelves. Breech presentations 
are especially to be dreaded in this form of 
pelvis, for it is very difficult to free the 
legs and arms, and to bring the head down 
through the contracted canal. Although the 
mother does not suffer from injuries to the 
soft parts which are incident to labor in 
some forms of contracted pelvis, still the 
pelvic joints are liable to be ruptured and 
eclampsia is very common. As for the child, 





Fig. 829. — Achondroplasic Dwarf. 
— (Depaiil.) 



Fig. 830. — Dwarf Pelvis. 



the caput succedaneum is of unusual size and is just over the smaller fontanelle. 
The cranial bones greatly overlap (Fig. 589). 

II. Simple Flat, Non-rachitic Pelvis (Fig. 911).— A frequent form of de- 
formed pelvis consists in the shortening of the antero-posterior diameter. This 
variety is common and was the first contracted pelvis to be recognized. It 
was not till later that the distinction between it and the rachitic flat pelvis 
was made clear. 

Frequency and Etiology. — The etiology is obscure, although, as a rule, this 
type of pelvis is probably congenital. It is a very common type and is found 
as often among the upper classes as among the lower; and it is also as common 
in the otherwise well-formed woman as in the stunted. Various predispos- 



678 



PATHOLOGICAL LABOR. 




ing causes of this deformity have been suggested, such as overexertion in 
youth; excessive burden -bearing; the combination of weak pelvic ligaments 
and a heavy trunk; arrested rachitis. It is probable that heredity is an im- 
portant factor, for it has been noted frequently in newly born children 
and fetuses. 

Clinical Characteristics. — It is only the antero-posterior diameter in this 
pelvis which departs from the normal, the other pelvic diameters being as a 
rule undisturbed. The degree of distortion is never great. The sacrum is 
displaced forward to a slight degree and the cartilage between the second and 

third sacral vertebrae is unusually 
prominent, often making a double 
promontory. The mutual relations 
between the iliac crests and spines 
are almost nil. Contrary to the con- 
dition in the generally contracted 
pelvis, vaginal palpation will recog- 
nize the lateral pelvic walls only with 
difficulty. The pelvis is perfectly 
symmetrical. 

Diagnosis. — Unless there has been 
difficultv in previous labors there will 
be nothing but the measurements to 
call attention to the condition, which 
is easily overlooked. In the presence 
of a double promontory the one 
nearest the symphysis must be used 
in measuring the conjugate. 

Prognosis. — Pendulous abdomen is 
often present in this form of pelvis. 
Labor need not be seriously interfered 
with, although instrumental delivery 
may be necessary under certain 
conditions, such as feebleness of the 
uterine contractions or oversize of the 
fetal head. The first stage is gene- 
rally protracted, for the head is longer 
than usual in engaging. After en- 
gagement has taken place, the course 
of labor runs smoothly, although the 
maternal strength may have been 
much exhausted by the demands 
made upon it before engagement took 
place. This condition of affairs will, of course, naturally protract the course of 
labor. The head accommodates itself to the shape of the pelvis; this accounts 
for its transverse position and slight extension as it enters the pelvis; which 
allows the palpation of the bregma (Fig. 653). The anterior parietal position 
is assumed, since the sagittal suture is brought near the sacral promontory 
(Figs. 693 and 694). Very infrequently the head assumes the posterior parietal 
position, so that the sagittal suture approaches the symphysis (Figs. 696 and 
697). This is generally confined to primiparae. Early rup'ture of the mem- 
branes is frequent. It is probable that in the majority of cases labor termin- 
ates spontaneously. Faulty presentations and prolapse of the cord or extremities 



Fig. 831.— Symmetrically Contracted Pel- 
vis from Complete Assimilation of the 
Fifth Lumbar Vertebra with the Sa- 
crum. 




Fig. 



of Pelvic 
Fig. S31. 



Inlet 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 679 

frequently occur. Necrosis of the maternal soft parts may be expected from the 
long pressure to which they are subjected. As to the child, although the caput 
succedaneum is not extreme, there are often depressions or grooves on the head 
varying with the position of the pressure to which it has been subjected. 

III. Generally Contracted Flat, Non-rachitic Pelvis (Fig. 912). — As the name 
indicates, this pelvis is characterized by the peculiarities of both the generally 
contracted and the flat pelvis. 

Frequency and Etiology. — This pelvis results from congenital defect but not 
from rachitis, and is rather common. Some authorities believe that it can be 
caused by too early walking or long standing on the feet in the first years of life. 

Clinical Characteristics. — With the exception of the diagonal conjugate, 
which may be increased on account of the elevation of the sacrum, all of the 
diameters are decreased, particularly the conjugate of the inlet. The sacrum 
is small, its promontory is much elevated but not prominent, while its position 
is considerably posterior in comparison with the normal. The alse as well as 
the innominate bones are not fully developed. Two points should serve to 
differentiate this type from the rachitic pelvis — the abnormally posterior posi- 
tion of the sacrum and the fact that the anterior half of the pelvic circumference 
is only slightly broadened. Otherwise there are various points of resemblance 
between this and the rachitic pelvis. The entire pelvis is smaller than normal. 
The mechanism of labor is similar to that in flat pelves. 

Diagnosis. — An absolute diagnosis can be made only by the direct measure- 
ment of the various diameters, and is even then difficult. Although these 
diameters throughout bear a resemblance to those of the generally equally con- 
tracted pelvis, the diagonal diameter is an exception, being longer in the last- 
named; this factor, together with the ease with which the side walls of the 
pelvis can be reached by the internal finger, will help in the diagnosis. 

Prognosis. — More difficulty in labor is experienced in this pelvis than in the 
simple flat variety, for the oblique diameters do not afford extra room for the 
head of the fetus, the whole pelvis being undersized. 

IV. The Narrow, Male, Funnel-shaped Pelvis ; Fetal or Lying-down or Un- 
developed Pelvis (Fig. 833). — The name suggests both the shape and the etiology 
of this type of pelvis. The subject of funnel-shaped pelvis has been much 
neglected. 

Frequency. — This has been considered an exceedingly rare variety, but is 
often found when the pelvis is systematically measured. Schauta estimated 
5.90 per cent, of funnel pelves in 5000 cases. 

Etiology. — It is due to the absence of the forces upon which the evolution of 
the normal pelvis depends. (Page 440.) Those unfortunates who, owing to 
infantile paralysis or for other reasons, have never walked are the ones in 
whom it is most markedly found. A suggestion of this type is also sometimes 
found in very young girls. Schauta pointed out the fact that this pelvis is 
generally due to maldevelopment by which the walls of the pelvis are lengthened 
and the body-weight is thrown backward on the sacrum. 

Clinical Characteristics. — The characteristics of the fetal pelvis persist — 
usually length and narrowness of the sacrum and elevation of the promontory 
which gives a longer diagonal conjugate than usual. The whole pelvis is very 
narrow and deep and there is not the normal width at the hips. The sacrum is 
unusually straight. The transverse diameter of the outlet is contracted, and 
Schauta showed that contraction in the pelvic outlet may be in any diameter. 
The sacrum is far back between the iliac bones. The spinal column is normal. 

Another Form of Funnel Pelvis. — A kyphosis in the upper vertebrae gives a 



680 



PATHOLOGICAL LABOR. 



lordosis in the lower part. If the kyphosis is lower, the influence on the pelvis 
is marked. Suppose the kyphosis is in the lumbar region, there is no compen- 
satory lordosis, but in order to enable the patient to stand upright there are 
changes in the pelvis causing an enlargement at the superior strait. Rotation 
of the sacrum backward causes an increase in the superior and a decrease in the 
inferior strait. The pelvis assumes more or less the horizontal position. The 
iliac bones are spread apart by the sacrum, causing the distance between the 
spines and crests to be increased. Great tension is put on the ilio-sacral liga- 
ments, causing a drag on the ischia, tending to spread the bones above and 
causing a contraction below from side to side. Hence the pelvic outlet is 
diminished both transversely and antero-posteriorly. The tension is on the 
ilio-femoral ligaments, and this throws the ilia outward and the ischia inward. 
A kyphosis, in order to produce this, must take place in early life. Later, the 

pelvis is tilted but no such change 
takes place. 

Diagnosis. — The diagnosis may 
be easy if measurements are taken. 
Usually the deformity is overlooked. 
The kyphosis itself should give the 
clue. The measurements of the 
inlet and outlet must be compared 
(see Pelvimetry). The diameters 
of the outlet are less than normal, 
while those of the inlet are normal 
or even greater. When this de- 
formity exists in an extreme degree, 
so that the inlet and the pelvic 
cavity are contracted, there is a still 
greater degree of contraction, com- 
paratively speaking, in the outlet. 
The internal examination of the 
pelvic canal is of great service in 
making the diagnosis, for it will 
clearly reveal the shelving walls 
converging toward the outlet, the 
contraction of the pelvic arch, and 
the close relation of the ischiac 
tuberosities and spines. 
Prognosis.— In more than one-half of the cases labor has terminated 
fatally. It may be possible to deliver with forceps, while spontaneous 
delivery takes place only in the slightest degree of this deformity. If the 
transverse diameter is less than three inches (7.62 cm.) and the anteropos- 
terior diameter is also contracted, symphyseotomy is indicated, while still 
greater contraction will demand Cesarean section. " Hence in these forms the 
ordinary means of pelvimetry are not sufficient for making the diagnosis. If 
the diagnosis is not made, the child will be dragged out through the contracted 
outlet. Faulty positions of the head at the outlet are common. The power 
of expulsion is generally weak. Lacerations and necrosis of the soft parts are 
most frequent, and on account of the convergence of the pubic rami there is 
great danger of perineal laceration. 

V. Imperfect Development of One Lateral Mass of Sacrum. Naegele's Pelvis. 
Obliquely Deformed or Contracted Pelvis. Obliquely Ovate Pelvis. Single 




Fig. 833. — Narrow, Male, Fuxxel-shaped, 
Fetal or Lying-down Pelvis. — (Ahlfeld.) 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 681 

Oblique Pelvis (Figs. 834, 835, 836, 837). — Naegele first described this in 1806, 
and published a work in 1839 in which he had collected some thirty cases. 

Frequency and Etiology. — By many obstetricians this pelvis is considered 
extremely rare, but careful observation will result in the discovery of one or 
two in the course of the average practice in obstetrics. There are two theories 
as to etiology: (1) Failure of development of the alas of the sacrum on one 
side from absence of bony nuclei; (2) inflammatory changes in the same place 
causing synostosis. Reasons for the congenital view are: (1) Such deformities 
have been observed in intrauterine life; (2) if it were due to inflammation, 
traces of this trouble would be left behind — but these are not found. The 
direction of distortion of the innominate bones is upward and backward on 
the sacrum. This condition would not be possible in the presence of primary 
ankylosis. The atrophy of the part embraces the whole length of the sacrum. 
It is to-day accepted that the first theory is the correct one. The ossification 
of the bones is secondary. Even children having this deformity before ankylosis 
takes place have the oval pelvis, because the well side in developing draws 
over the affected side. As soon as the patient begins to walk, the body-weight 
is applied more to the leg of the diseased side, causing an adhesive inflammation 
leading to synostosis. Sometimes this union does not take place, but the 
pelvis is deformed notwithstanding. 

Clinical Characteristics. — The sacral ala on the deformed side is atrophied 
or entirely wanting, while there exists a synostosis between the sacrum and 
the iliac bone. The asymmetrical narrow sacrum faces the deformed side, 
the promontory being actually twisted over toward the contracted side. The 
pelvic inlet is oval in shape, with the tapering end on the deformed side (Fig. 
836). The crests of the pelvis are markedly asymmetrical. The symphysis 
is deflected from the middle line to the unaffected side, while the pubic arch is 
contracted and deflected (Figs. 836 and 919). The external surface of the sym- 
physis faces toward the diseased side instead of directly forward. The ilio- 
pectineal line of the affected side is almost a straight line, while the ilium on 
the sound side has a greater curve in its anterior part than normal, but in 
every other particular is practically unchanged. The posterior superior spine 
of the ilium approaches the sacral spines. The oblique diameter drawn from 
the superior posterior spine of the ilium of the deformed side to the anterior 
superior spine of the normal side is increased (Fig. 837). Careful internal 
pelvimetry will detect considerable decrease in the oblique diameter drawn 
from the point just above the center of the obturator foramen on the con- 
tracted side to the opposite sacro-iliac synchondrosis. Pressure of the femur 
on the diseased side is exerted in an upward direction, so that the innominate 
bone is pressed upward and inward, while on the sound side femoral pressure 
is directed upward and outward. Thus the sound side is enlarged. This fact 
is of importance because in the mechanism of labor there is only one side of 
the pelvis for the fetus. The normal true conjugate plays no part. The 
diameter to be considered skirts the posterior wall at the sacro-iliac syn- 
chondrosis. There is no shortening of the true conjugate, and therefore these 
pelves are often unrecognized. 

Diagnosis. — This is readily made in routine pelvic examinations, although 
without careful measurements the deformity may be easily overlooked. In 
the internal examination the asymmetry ought to be recognized by the ischial 
spines. The contracted pubic arch and distorted promontory would also 
be noticed. 



682 



PATHOLOGICAL LABOR. 



The distance is measured from the spine of the last lumbar vertebra to the anterior 
superior spines of the ilia, and from the last lumbar spine to the posterior superior spine. 

Then the measure is taken from 
the anterior superior spine of 
one side to the posterior supe- 
rior spine of the opposite side; 
from the posterior superior spine 
of the ilium on one side to the 
tuber ischii on the other; from 
the posterior superior spines of 
the ilia to the inferior edge of 
the symphysis pubis; from the 
inferior edge of the pubis to the 
spines of the ischium, and again 
from the spines to the nearest 
sacral borders. The longest 
measurement between the ischial 
spines and the inferior border of 
the pubis is on the decreased 
side, while the reverse is true 
of the distance between these 
spines and the sacrum. 

The majority of these 
cases have been diagnosed 
after death. Zweifel be- 
lieves the diagnosis to be 
free from difficulty when 
there is a great difference 
between the sides. The 
patient may exhibit no limp 
in her gait, but a careful 
history of her early life 
should be obtained. Phy- 
sical examination may also 
reveal healed sinuses. A 
rectal examination is valu- 
able for detecting an anky- 
losed joint. Externally the 
most valuable measurement 

that from the trochanter 




Fig. 834. — Oval Oblique Pelvis 
(Budin.) 



Naegele. — 




Fig. 835. — Oval Oblique Pelvis of Naegele. 
vie Inlet. — (Author's collection.) 



Pel- 



is 

major of one side to the iliac 

crest of the other, and vice 

versa. 

Prognosis. — The results 
are usually fatal. Probably 
two-thirds of the cases pass- 
ing into labor have ended 
in death. If the deformity 
is great, the child must 
pass through the healthy 
side of the pelvis, as the 
contracted side is not large 
enough to admit any part 
of the fetus. The mechan- 
ism is similar to that of the 
generally contracted pelvis. 
The occiput descends first, 



J 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 



683 



as the head is extremely flexed 
unfavorable, for it may be 
impossible for the head to 
pass. The mortality of the 
mothers is 80 per cent., ac- 
cording to Litzmann. The 
prognosis in respect to the 
mother will necessarily de- 
pend upon several factors. 
Eighty per cent, as quoted 
is thought to be too high 
for maternal mortality, and 
it is to be accounted for 
by the use of inappropriate 
treatment, and also by the 
fact that often the condi- 
tion was not recognized 
early enough for the use 
of suitable therapeutic 
measures. Various acci- 
dents are apt to take place 
during labor, such as rup- 
tures, fistulae, fractures, etc. 

Treatment. — This differs 
according to the extent of 
the deformity. If the infe- 
rior strait is contracted, 
Caesarean section should be 
performed. Farabeuf re- 
commends ischio-pubotomy. 
(See Operations, Part X.) 
If the attendant is in doubt, 
Caesarean section should be 
performed, since unless the 
degree of deformity is 
slight, forceps and version 
are not generally attended 
by good results. 

VI. Imperfect Develop- 
ment of both Lateral Masses 
of the Sacrum, Robert's Pel- 
vis. The Ankylotic Pelvis. 
Transversely Contracted Pel- 
vis (Figs. 838, 839).— Robert 
was the first to describe this 
pelvis in 1842. It is closely 
related to the Naegele pelvis. 
Frequency and etiology: This 
is the rarest of contracted 
pelves, only eight cases hav- 
ing been reported. It is 
due to failure of develop - 



If the breech presents, the prognosis is more 




Fig. 



836. — Oval Oblique Pelvis 
(Budin.) 



of Naegele. — 




Fig. 837. 



-Oval Oblique Pelvis of Naegele. 
vie Outlet. — (Author's collection.) 



Pel- 



684 



PATHOLOGICAL LABOR. 



ment of the sacral alas on both sides. There is generally synostosis on both 
sides, and the sacro-iliac synchondrosis is absent. Clinical characteristics: The 
sacral alas are either absent or poorly developed. The narrow sacrum has an 
extremely elevated promontory, felt on internal examination. The spines and 
tuberosities of the ischium are more closely approximated than normally. The 
transverse pelvic diameters are much decreased, while on account of the slight 
anterior displacement of the sacrum the conjugate of the superior strait is 
diminished. The transverse diameter of the inlet is particularly shortened, 
varying, according to Kleinwachter, from 2.76 to 3.94 inches (7 to 10 cm.), 

while that of the outlet is 
from 0.88 to 2.76 inches 
(2.25 to 6 cm.). The pubic 
angle is diminished. Asym- 
metry of the Robert pelvis 
sometimes exists. Diagnosis 
is based upon the above 
condition. Prognosis: Cas- 
sarean section with its at- 
tendant dangers is nearly 
always indicated. Treat- 
ment: Perforation and ex- 
traction may be performed 
within certain limits, a case 
in which the transverse 
diameter of the pelvic inlet 
measures 3.1 inches (7.8 
cm.) and that of the outlet 
2 inches (5 cm.) is supposed 
to represent the extreme 
limit of its applicability. 
Cassarean section has been 
performed in the majority 
of the cases. 

VII. Generally Equally 
Enlarged Pelvis. Pelvis 
-5£quabiliter Justo-major. 
Giant Pelvis. Justo-major 
Pelvis (Figs. 840 and 841). — 
This pelvis is occasionally 
observed in women of med- 
ium height, although it also 
sometimes accompanies a 
gigantic stature. Frequency 
and etiology: This condition 
is often merely congenital, with no other particular explanation. Clinical 
characteristics: In this pelvis all the diameters, although preserving normal pro- 
portions, are increased. The condition is seldom noticed, especially if not 
present in an extreme degree. During pregnancy the woman is liable to have 
increased pressure symptoms. This is due to the low position of the uterus in 
roomy pelvis. Constipation, urinary symptoms, oedema of the vulva, 
and difficult locomotion are common in pregnancy. Diag- 
nosis: This is rarely made, but if measurements show a general and sym- 




Fig. 838. — Double Oblique Pelvis of Robert. 




Fig. 839. 



■Double Oblique Pelvis of Robert. 
gram of pelvic inlet of Fig. 838. 



Dia- 



the 
varicose 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 



685 




Fig. 840. — Generally Equally Enlarged Pelvis. 
Justo-major Pelvis. Pelvic Inlet. — {Author's 
collection.) 



metrical increase, diagnosis of a justo-major pelvis is justifiable. The pro- 
montory cannot be reached by internal examination, nor are the side walls 
of the pelvis easily accessible. Prognosis: Labor is usually not disturbed by 
this anomaly, although the majority of obstetricians consider that delivery is 
apt to be precipitate on account of the large size of the birth canal. 

VIII. Split Pelvis. Inverted Pelvis (Fig. 842). — The name and illustration 
indicate the deformity. Fre- 
quency and etiology: This con- 
dition represents an anomaly 
of non-union, comparable and 
usually associated with such 
malformations as exstrophy of 
the bladder, myelomeningo- 
cele, etc. As a complication 
of labor it is one of the rarest 
of pelvic anomalies. Clinical 
characteristics: Although the 
deformity of this type most 
frequently concerns the sym- 
physis pubis, still in some cases 
the sacrum as well as the lower 
part of the vertebral column 
is fissured at birth. In the 
separation of the pubic bones 

the heads of the femora, pressing upward, force the innominate bones outward 
and backward, resulting in the approach of the posterior superior spines of 
the ilium behind the sacrum, which is pushed inward. Thus there is 
created a groove posterior to the sacrum, from which circumstance this 
variety of pelvis receives the name of "inverted" pelvis. The space where 

the bones fail to meet is usually 
filled with fibrous tissue. Exstro- 
phy of the bladder usually ac- 
companies this deformity. Not 
infrequently there are other con- 
genital defects. It is not often that 
this pelvis is observed in a woman 
who bears children, though there are 
several recorded cases. The diag- 
nosis is perfectly clear. Prognosis: 
Xo obstacle to labor is presented 
by the deformity, and it may be 
compared with the justo-major pel- 
vis. There is no indication for ob- 
stetric treatment during labor. There 
is almost invariably prolapsus uteri 
after labor. In the case of cleavage 
of the sacrum there is often present 
a meningocele projecting into the pelvis which may offer a serious obstruction 
to the passage of the child. 




Fig. 84 i. — Generally Equally Enlarged 
Pelvis. Justo-major Pelvis. Pelvic 
Outlet. — -{Author's collection.) 



PATHOLOGICAL LABOR 




Fig. 842. — Split or Inverted Pelvis. 




Fig. 844. — Pelvic Inlet of Fig. 843. 




Fig. 843. — Pelvis Deformed from In- 
fantile Paralysis of the Right Side 
with Atrophy of the Corresponding 
Femur. 




Fig. 845. — Pelvis Deformed from 
Faulty Development of the Sa- 
cral Vertebra. 




Fig. 846. — Deformed Pelvis from Faulty 
Development of the Sacrum. 



Fig. 847. — Pelvis Deformed from Faulty 
Development of the Sacral Vertebra. 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 



687 



B. ANOMALIES DUE TO DISEASE OF THE PELVIC BONES. 

I. Rachitis or Rickets. Rachitic Pelvis. — This deformity has doubtless 
always existed. Hippocrates and Galen knew of it, but Glisson (1650) first 
described the disease. Rickets of the newly born child may be one of two 
varieties — fetal or congenital. It was the former that was familiar to the 
ancients, as the latter has been recognized only of late years. Both types of 
this disease begin in intrauterine life, but while in the fetal form the stigmata 







Fig. 848. — Zone of Ossification in a 
Normal Epiphysis (Microscopic): i, 
Hyaline cartilage; 2, zone of beginning 
proliferation of the cartilage ; 3 , columns 
of cartilage-cells arranged in rows; 4, 
columns of enlarged cartilage-cells; 5, 
first zone of calcification; 6, layer of 
osteoblasts in first zone of ossification; 
7, fully developed cancellous tissue 
(spongiosa) ; 8 and 9, blood-vessels in 
transverse and longitudinal section. 




Fig. 849. — Zone of Ossification in a 
Rachitic Epiphysis (Microscopic): i, 
Transition of normal hyaline cartilage 
to proliferating cells; 2, zone of carti- 
lage-cells arranged in rows; 3, cellulo- 
fibrous medullary spaces containing 
blood-vessels in the region of the pro- 
liferated and enlarged cartilage-cells; 4, 
island of calcified cartilaginous tissue; 
5, columns of osteoid and fully devel- 
oped calcified bone-tissue; 6, columns of 
osteoid tissue not containing lime-salts ; 
7, like 3, with the blood-vessel in trans- 
verse section. 



of the disease are fully developed at birth, in the congenital form the evidences 
of the disease continue .their development after birth. Fetal rachitis has been 
called a disease of the periosteal cartilage. There is an exuberance of growth 
of this part while the process of calcification is faulty. In rachitis the growth 
of the cartilage and subperiosteal tissue is defective as well as the process of 
calcification. (See Antenatal Pathology, Part III, page 285.) 

Frequency and Etiology of Rachitis. — From fifty to seventy per cent, of 
dispensary patients in Glasgow and Vienna exhibit traces of this affection. In 



688 



PATHOLOGICAL LABOR. 



America it is especially seen in the colored race. In the lower animals there 
occurs a disease similar to rickets. Malnutrition of the mother and deficiency 
in lime salts seem to be the most important etiological factors. 

Pathology of Rachitis. — Bone is normally formed (i) under the periosteum, 
(2) from cartilage, (3) from the medullary canal. All of these may be affected 
by the disease. The essential fact is that there is excessive bone-formation 
while calcification is limited. Hence it is. a primary disease — never caused by 
solution of pre-formed calcified bone. RolofI noted that in zoological gardens 
lions fed on meat without bones develop a similar condition (lahme) on account 
of the lack of calcium (Figs. 848, 849). 

Clinical Characteristics of Rachitis. — Rachitis is a disease of children occurring 
during the first three years of life. If the child has already learned to walk, it 
ceases to do so. Hence, one should always ask "when the patient learned to 

walk." The disease gives rise to 
soft bones, with their resulting de- 
formities. The epiphyses of the 






Fig. 850. — Sagittal Section of a Rachi- 
tic Pelvis. Note the false sacral pro- 
montories and the disappearance of the 
vertical concavity of sacrum. 



Fig. 851. — Sagittal Section of a Rachi- 
tic Pelvis. Contraction at the pelvic 
inlet with exaggeration of the vertical 
concavity of the sacrum. 



long bones are enlarged (''knock-knee, rachitic rosary"). This is more marked 
on the pleural than on the pectoral side of the ribs. Pigeon -breast often results, 
especially if adenoids are associated. The head is more or less square or blunt. 
The bones of the skull have flat areas, which are thinned, and spoken of as 
craniotabes. Gastro-intestinal symptoms are marked and marasmus may result. 
The various parts of the body are disproportionate, the abdomen being very 
large. Hydrocephalus and enlarged thyroid are often present. The pelvis 
and spinal column are subject to deformities. In certain cases the head is 
inclined laterally upon the axis of the spine. The long bones are often curved, 
while their spontaneous fracture is not uncommon. Diagnosis from recog- 
nition of the clinical characteristics as given above should be simple (Fies. 8^0, 
851,852). * 

Varieties of Rachitic Pelves.— There are several varieties of deformed pelvis 
resulting from the inroads of this disease. The most frequent is (1) flat rachitic 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 



689 



pelvis, in which, although all of the diameters are shortened, the antero-posterior 
is most affected. (2) The simple flat, rachitic pelvis, in which the transverse 
diameters suffer no change. (3) The generally equally contracted rachitic 
pelvis. (4) The pseudo-osteomalacic pelvis, which comes to resemble the 
pelvis of osteomalacia from the effect of pressure on the soft rachitic bones. 
(5) Very rare forms of distorted pelves, in addition to the foregoing, result 
from rachitic affections of the spinal column. 

Clinical Characteristics of Rachitic Pelves. — Three influences serve to modify 
the pelvis in rachitis: (1) Arrest of development occasioned by the progress 
of the disease; (2) the pressure exerted both by the superimposed skeleton and 
the subjacent skeleton; and lastly (3) the "pull " of the ligaments and muscles 
attached to the pelvic bones. The pelvis 
as a whole is undersized, having a dis- 
torted inlet which is often kidney-shaped 
or rarely like the figure 8. The pelvic cavity 
is very shallow. The pull of the obturator 
muscles upon the soft bones widens the 
pubic arch, and if great flattening is pres- 
ent, there will result the figure 8 pelvis. 
The promontory of the sacrum is abnormally 
prominent. The obliquity of the pelvis is 
greatly increased. The epiphyses are pecu- 
liarly altered, while the presence of other 
characteristics of rachitis adds to the cer- 
tainty of the diagnosis. As a rule, the bones 
of a rickety pelvis are abnormally fragile 
and small; rarely they are coarser and heavier 
than normal. (1) and (2) Rachitic flat pel- 
vis: As a result of softening of the bones the 
child learns to walk late, or if it has walked 
ceases to do so for a time (Figs. 853, 854, 
855, 856). The bones are soft and the 
child does not walk, but sits up; hence the 
pressure of the body-weight is not counter- 
acted by the upward pressure of the femora. 
The broadening becomes marked and the 
transverse diameter is shorter than normal. 
The iliac bones are flared out so that the 
iliac spines are farther apart than the crests. 
The sacrum tends to rotate, imparting a 
backward impulse to the lower part, but this 

is offset by the firm grasp of the ligaments, and a curve is the result. Hence 
the antero-posterior diameter of the inferior strait is shortened. The bodies 
of the sacral vertebras are pushed forward at the expense of the alae, making 
the anterior surface of the sacrum straight or convex. The child sits on the 
tubera ischii without the upward pressure of the femora to counteract, and 
the transverse diameter of the inferior strait becomes broadened, and there is 
also a flaring outward of the ischiac bones. The area of the superior strait 
remains about the same, but the relations are distorted. Owing to the back- 
ward movement of the sacrum, there is more room in the pelvis, although the 
external antero-posterior diameter of Baudelocque is less than normal. The 
interference with labor ends when the head has passed the superior strait. 
44 




Fig. 852. — Rachitic Dwarf. De- 
livered by Cesarean Section. — 
{Author's case.) 



690 



PATHOLOGICAL LABOR. 




Fig. 853. — Rachitic Pelvis. Diminution of Fig. 854.— Pelvic Inlet of Fig. 853. 
all diameters, especially of the antero-pos- 
terior. 




Fig. 855. — Simple Flat Rachitic Pelvis. Note the Fig. 856. — Pelvic Inlet of Fig. 855. 
false sacral promontories. 





Fig. 857. — Generally Equally Contracted Fig. 858. — Pelvic Inlet of Fig. 857. 
Rachitic Pelvis. 



J 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 



691 



The effect of the deformity varies according to the extent. As to the measure- 
ments of the pelvis, a true conjugate, one less than 2 J inches (5.5 cm.), is 
absolutely contracted; 2\ inches (6.35 cm.) to 3 inches (7.62 cm.) is a deformity 
of the third degree; 3 inches (7.62 cm.) to 3^ inches (8.89 cm.) is a deformity 
of the second degree, and the child may be born spontaneously or with the 
aid of the forceps; 3J inches (8.89 cm.) to 4^ inches (10.795 cm -) ^ s a deformity 
of the first degree, and the first child 
is usually born spontaneously. Con- 
tractions of the first degree are of 
little importance. The child's head 
is 3! inches (9.5 cm.) for the biparie- 
tal diameter, but this is capable of 
considerable shortening. In a flat 
rachitic pelvis the head is less flexed, . 
being semi-extended. The two fon- 
tanelles are on the same level. The 
head becomes tilted in normal cases 
so that the sagittal suture lies nearer 
the promontory of the sacrum. This 
is called Naegele's obliquity. (Pages 
571, 606.) In flat rachitic pelves this 
is accentuated and the sagittal suture 
lies in front of the sacrum and the 
parietal bone presents — anterior par- 
ietal presentation. This increases till 
finally the ear is left behind the sym- 
physis pubis. Then rotation takes 
place, causing the sagittal suture to 
leave the sacrum (Figs. 769 and 
770). In a few cases the sagittal 
suture is anterior. The complication 
is then more serious, as the head 
becomes wedged above the symphysis 
pubis. Whenever the two fontan- 
elles are felt equally, a flat rachitic 
pelvis may be suspected. After the 
head has passed the superior strait 
the mechanism of labor is normal. 
Presentation by the posterior parietal 
bone is serious because the head is 
wedged on the symphysis pubis. The 
child cannot be born spontaneously 
(Fig. 771). Great pressure is exerted p IG 
on the posterior parietal bone by the 
sacrum, causing a depression in the 

bone. Sometimes this depression is spoon-shaped. It is quite likely that 
the brain has been injured. By palpation only a vague idea of the size 
of the head can be obtained. (3) The generally equally contracted rachitic 
pelvis: This is chiefly characterized by arrested development (Figs. 857, 
858). This entails contraction of the transverse diameter such as is seen in 
the fetal pelvis. This form is very rare and it leaves the shape of the 
pelvic brim little changed from normal, since the ravages of the disease 




859. PSEUDO-OSTEOMALACIC RACHITIC 

Pelvis. — {Author's collection?) 



692 PATHOLOGICAL LABOR. 

have done their work at such an early age that the child has not sat up 
or walked till recovery had taken place. Consequently the processes which 
serve to change the shape of the pelvis when disease offers them in a favorable 
condition, have not had a chance to exert their influences. (4) The pseudo-osteo- 
malacic pelvis: This is the result of several conditions the opposite of those 
considered in the last section (Fig. 859). The deformity of this type is 
striking, for the disease progresses while the child is walking and perchance 
carrying heavy weights (Fig. 859). From the action of the two forces, 
superimposed and subjacent, the pelvis is distorted to an extreme degree. 
The acetabula are pushed inward so that they encroach on the pelvic space. 
The innominate bones yield to the pressure exerted upon them and are bent 
laterally, while the sacrum is pressed downward and bent also in the same 
direction. The deformities are far advanced before the disease has exhausted 
itself, and the pelvis is fixed in its distorted form. 

Diagnosis of Rachitic Pelves. — Signs of rachitis in other parts of the body 
will make the diagnosis more clear. The history of infantile rachitis also can 
generally be elicited. The relative position of the crests and spines of the ilia is 
of important diagnostic significance (Fig. 860). The history and personal appear- 
ance must also be taken into consideration. After rachitis in childhood 

the woman is generally ob- 
served to be short with thick, 
curved limbs, enlarged joints, 
square head, and chicken- 
breast. The abdomen is 
short, and on this account, 
and because of the failure of 
engagement of the presenting 
part, when pregnancy occurs 
it hangs far forward and 

downward in a characteris- 
Fig. 860. — Diameters of the Iliac Spines axd .- r» -j 11 • 

Crests in a Rachitic Pelvis Compared. D.M., tlC manner - Besides walking 
Intercristal diameter; D.A., interspinal diameter. late, the rachitic child is late 

in teething. Not infrequently 
a double sacral promontory is observed in these patients. In some cases the lum- 
bar vertebras are curved inward so far that they offer an obstruction above the 
brim. This results from rachitis of the spine. In measuring the effective 
conjugate from the symphysis the outer point must be taken above the sacrum. 
To differentiate this pelvis from that of osteomalacia is not difficult, for there 
are characteristics belonging to the latter which clearly distinguish it, and, 
besides, the other rachitic signs come into play — those found elsewhere in 
the body and the direction of the crests of the ilia. After the disease has run 
its course the consistency of the bones is firm and hard. 

II. Osteomalacia. Osteomalacic Pelvis (Figs. 861 to 865). — In English 
works the disease is called malacosteon. The pelvis in a patient suffering from 
this disease is called the "osteomalacic," "malacosteon," or " Y-shaped pelvis." 
It is also known as the "beak-shaped " or "rostrate pelvis." Frequency and 
etiology: It is rare in America but very common around the head-waters of 
the Rhine. Litzmann's statistics (1892) show that of 131 cases 11 were in 
males, 85 in pregnant or puerperal women, and 35 in non -pregnant women. It 
is essentially^ disease of women, being in them about five times more fre- 
quent than in men. It occurs during pregnancy or during the puerperium. 
This disease is caused by the production of soft bone in the adult through the 




MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 



693 



absorption of lime salts (Fig. 86 1). This bone is unable to resist pressure 
without being distorted into bizarre forms. It usually occurs between thirty 
and fifty years of age, in pregnant women or in those who have had children, 
and especially in those who have had many children. It is observed in 
animals kept in zoological gardens, where it is usually thought to differ 
from the similar condition in human beings. Varieties of osteomalacic 
pelves: The relative deformity from malacosteon may be expressed by several 
forms of pelves: (i) Oblong, in which the antero-posterior diameter is in- 
creased (Fig. 862); (2) oblong rostrated, oblong in shape with anterior beak 
(Figs. 863, 864, 865); (3) rostrated, with beak in front; (4) cordiform, heart- 
shaped. This last form is very rare. Pathology: The old idea was that 

bones affected with this disease contain 
far less calcium than the normal bone. 
In 1895 Curatulo and Turelli made animal 
experiments. They estimated the total 
excretion of carbonic acid, lime, and 
phosphoric acid. Then they cut out the 
ovaries and found certain changes. The 
animals did not breathe so rapidly and 
excreted less lime and phosphoric acid. 



-■■■ ^' 





Fig. 861. — Micros 



COPIC 



Section Fig. 86 2. — Osteomalacic Pelvis. Oblong In- 



THROUGH AN OSTEOMALACIC BOXE. 

i, Remains of calcified bone-sub- 
stance; 2, decalcified bone-substance ; 
3, large medullary spaces due to the 
disappearance of bone-substance; 4, 
Haversian canals. 



LET BEFORE MUCH DEFORMITY HAS OCCURRED. 

Weight of this pelvis fifteen ounces. Weight 
of healthy bony pelvis about thirty ounces. — 
(Author's collection.) 



Hence it was shown the ovaries increase the excretion of these products. In 
1896 Denecke estimated the amount of lime and phosphorus excreted by osteo- 
malacic women ; the ovaries were then removed. In a few weeks there was a 
marked decrease in the excretion of these substances. In 1897 Senator recorded 
a case of osteomalacia. Excretion estimates were made and the diet carefully 
regulated, while thyroid extract was administered. It was found that the ex- 
cretion of lime and phosphorus was increased. Ovarian extract caused an in- 
crease of nearly double that noted under the thyroid treatment. Clinical charac- 
teristics: The patient suffers from rheumatoid pains, inability to walk, and difficult 
labors. The pelvic bones become very soft so that in extreme cases they 
can actually be bent by the hand; they are also very painful. The pelvis 



694 



PATHOLOGICAL LABOR. 




Fig. 863. — Osteomalacic Pelvis. Oblong Ros- 
trated. Pelvic Inlet. 



naturally becomes much distorted and the symphysis pubis comes to resemble 
a beak, because the heads of the femora drive the innominate bones inward, 

while the symphysis is held 
in place by its muscular at- 
tachments. On internal ex- 
amination the finger may be 
laid in the hollow of this de- 
formity (Fig. 865). The pubic 
arch is much narrowed and 
the true conjugate is very 
short. The promontory of 
the sacrum is very prominent, 
being forced downward and 
forward, while the tip of this 
bone and the coccyx bend so 
sharply forward that the 
outlet of the pelvis is almost 
completely obstructed. The 
tubera ischii are displaced 
outward so that the trans- 
verse diameter of the outlet 
is increased. The patient 
surfers from dyspnea and 
cough. The bones become 
very porous and light, con- 
taining much cancellous tis- 
sue. This tissue contains 
large cavities, which may be 
from two to four millimeters 
in length. The pelvis actually 
collapses and the sufferer 
always loses markedly in 
height, — even as much as a 
foot in some cases, — while, 
unable even to stand, she is 
confined to her bed. It occurs 
during pregnancy, its first sig- 
nal being rheumatoid pains, 
and it may be diagnosed as 
rheumatism. This continues 
till the child is born, after 
which the woman is some- 
what lame, and the trouble 
returns at the next preg- 
nancy and difficult labor fol- 
lows. The second child will 
probably be born dead while 
the following will be delivered 
by craniotomy or abdomi- 
nal section. (See Osteomala- 
cia in Diseases of Pregnancy.) Diagnosis: The length of the true conjugate 
is not a criterion of the capacity in the pelvis, but the diagnosis can be made 




Fig. 864. — Diagram of Pelvic Inlet of Fig. 863. 




Fig. 865. — Osteomalacic Pelvis. Oblong Ros- 
trated. Pelvic Outlet. 



MATERXAL DYSTOCIA FROM OBSTRUCTED LABOR. 



695 




j&<^0$jk 



Fig. 866. — Large Exostosis of the Pubis. 









by a review of the clinical symptoms together with careful internal and external 
examinations. The peculiar pains attendant upon this disease, the peculiarity 
of the gait, and finally the 
total inability to walk, 
the characteristic beak- 
like pelvis, with almost 
complete obstruction of 
the outlet, the loss of 
height, all make a strik- 
ing clinical picture. 
Other types to be thought 
of in making the diag- 
nosis are: the pseudo- 
osteomalacic, the Robert, 
the kyphotic, or a pelvis 
which has been fractured 
or invaded by malignant 
disease. Prognosis: It is 
not in itself a fatal dis- 
ease. The patients usu- 
ally die of inanition. 
The obstruction is very 
marked even though the 
bones are so flexible. Out 
of 85 cases reported by 
Litzmann, 47 were fatal. 
Treatment: If taken in 
the beginning, an im- 
provement in surround- 
ings is indicated, as are 
oleum morrhuae and ton- 
ics. Phosphorus has been 
used. Ovariotomy ought 
to be done, especially as 
these women are usually 
very fertile. Hysterecto- 
my gives the best re- 
sult. Sometimes the sup- 
pression of the sexual 
functions may even cure 
the disease. 

III. New Growths.— 
The presence of exostoses 
or other kinds of tumors 
of the pelvic bones is 
very infrequent. But 
such growths may be 
the cause of a high degree 
of dystocia. The pelvis 
with bony exostoses (Figs. 
866 and 867) is known 
as acanthopelys, acan- Fig. 868.— Osteosarcoma of the Pelvic Cavity.— (Bar.) 




Fig. S67. — Exostosis of the Sacral Promontory 




696 



PATHOLOGICAL LABOR. 



thopelvis, pelvis spinosa, spiny or thorny pelvis, and Hauder's pelvis. It is 
believed that exostoses are found, as a rule, in pelves otherwise deformed, and 
they are generally situated over one of the pelvic joints. In their original state 
they are composed of cartilage, afterward becoming bony. Most of them 
are small — about the size of a small bean or olive, though now and then they 
may attain the dimensions of a pigeon's egg. In some cases spicules of bone de- 
velop at certain points in the pelvis, projecting into its cavity. They are very 
apt to injure the uterus or the descending head. Perforation of the uterus 
is common under these circumstances. After fracture of the bones irregular 
callus may also form projections. Other pelvic tumors are osteosarcomata (Fig- 
868), enchondromata, sarcomata, fibromata, cysts, and carcinomata. Their size 
will form the criterion for the difficulty offered in labor. The cysts may be hyda- 
tid or may be formed in enchondromata or sarcomata. Cancer is never primary. 
It may be an extension from the original focus or it may be metastatic. The 
growth may infiltrate the bones, making them porous and soft, as in oste- 
omalacia. Prognosis: According to Winckel, in 49 cases of pelvic tumor ob- 
structing labor, the maternal mortality was 50 per cent, while the fetal was 90 





Fig. 869. — Pelvis Deformed by Mul- 
tiple Fractures. — (Von Martz.) 



Fig. 870. — Pelvis Deformed by Multi- 
ple Fractures. — (Paparoine and Tar- 
nier.) 



per cent. Treatment: Cesarean section is generally performed, although the 
posterior vaginal wall has been excised and the growth removed by this route. 

IV. Fractures. — Out of 13,200 fractures from the statistics of nine hospitals 
in England and America, only f of 1 per cent, were fractures of the pelvis (Hirst). 
Contracted pelves may result from fractures and dislocations, whether con- 
genital or occurring later. These pelves are not symmetrical, and when the 
traumatism has taken place very early are sometimes undeveloped, and are 
always accompanied by grave deformity. The contraction is found on the side 
of the fracture. Nearly all cases of serious pelvic fracture end fatally. The 
resulting deformity may be of various forms, depending upon the nature and 
seat of the fracture (Figs. 869 and 870). If the horizontal pubic ramus is 
broken, it is impossible to keep the broken ends together during repair, and 
thus great deformity may result. In unilateral dislocations the resulting pelvis 
is obliquely contracted. A similar deformity is seen in the pelvis resulting 
from the early loss of one leg (Sitz pelvis, page 679, Fig. 833). 

V. Atrophy, Caries, and Necrosis.— An oblique contraction occurs sometimes 
in the rare event of tuberculosis of the sacro-iliac joint. In affections of this 
joint there will develop the same result as that in a true Naegele pelvis from 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 



697 



imperfect development of an ala of the sacrum. If the trouble takes place in 
early life, there will be loss of substance, arrested development of the part 
affected, and an anchylosed joint, all of which result in atrophy of the pelvis. 



SACRO-COCCY.AIT 



C. ANOMALIES IN THE JUNCTION OF THE PELVIC BONES. 

I. Synostosis at the Symphysis. — The development of synostosis in this joint 
is quite common and occurs most often during early childhood. This condition 
would present a difficulty in the operation for symphyseotomy, but although 
it would limit the expansion of this joint which normally takes place during 
labor, it is not a serious complication in otherwise unobstructed labor. 

II. Synostosis at One or Both of the Sacro-iliac Joints. — Synostosis of this 
joint occurring in early life is succeeded by badly developed sacral alas on the 
abnormal side; the part of the innominate bone concerned in this joint suffers 
also in its development, so that there 
results an obliquely contracted Xaegele 
type. Arrested development of the alae 
of the sacrum as a primary occurrence is 
far more frequently seen than this latter 
affection. If, instead of taking place in 
earh* childhood, the synostosis does not 
occur till after puberty, the untoward 
effects may be considered of no conse- 
quence. In case this affection takes place on 
both sides, there results a pelvis much like 
the Robert. This is still less frequent than 
the transversely contracted pelvis, owing 
to faulty development of the sacral alae. 

III. Synostosis at the Sacro-coccygeal 
Joint. — The joint between the sacrum and 
the coccyx is anchylosed, as a rule, between 
the thirtieth and fortieth years, but since 
the joint between the first and second 
coccygeal vertebrae does not take part in 
this process the effect on labor is scarcely 
worth considering. There is now and then 

a case in which anchylosis takes place in ail the joints of the coccyx as well 
as in the sacro-coccygeal joint, especially in elderly primiparas (Fig. 871). 
If labor occurs in such a patient, it will be necessary to fracture the coccyx 
or to break up the anchylosed sacro-coccygeal joint. The fracture sometimes 
takes place during the natural passage of the head down through the pelvic 
outlet, but it occurs more commonly in instrumental delivery. 

IV. Exaggerated Motion or Separation of the Pelvic Joints. — This may be just 
an exaggeration of the normal condition of the joints during labor. However, 
it will more probably have a pathological foundation, such as inflammation 
of the joints, succeeded by suppuration, fluid in the joint, new growths, caries, 
or osteomalacia. During labor there is sometimes a predisposition of the joints 
to rupture on account of the relaxation incident to pregnancy and labor. Some- 
times locomotion during pregnancy is made difficult by the relaxation of the 
joints. (See Part II.) The coccyx has been known to become dislocated 
during labor. This condition is productive of much pain, and often demands 
excision of the bone. 




Fig. S71 



Anchylosis of the Coc- 
C v x . — ■ (.4 it titer's collection.) 



698 PATHOLOGICAL LABOR. 

D. ANOMALIES OF THE PELVIS DUE TO DISEASE OF THOSE PARTS OF THE 
SKELETON WHICH ARE CARRIED BY THE PELVIS. 

i. Spondylolisthesis. Spondylolisthetic Pelvis, Kilian' s Pelvis, Rokitansky's 
Pelvis, Prague Pelvis (Figs. 872 to 877). — The term originated with Kilian, 1853, 
and is derived from spondylos (aicdvdvXos)-, vertebra, and olisthesis (<tti<rOeffi<;) } " a 
slipping out "or " down." Rokitansky, Kiwisch, and Seyfert had described the 
deformity, but Kilian gave the first accurate description. Neugebauer and Lane 
also did much work on the subject. To cause pelvic obstruction spondylolisthesis 
must take place in the lumbosacral region, and in obstetrics we understand the 
term to indicate a dislocation of the last lumbar vertebra in front of the base of the 
sacrum, so that the inferior surface, or possibly the anterior surface of the former, 
comes in contact with and is united by bony union with the anterior surface of the 
first piece of the sacrum. As a result a marked lordosis occurs in the lumbar ver- 
tebras, and the fourth, third, and possibly the second lumbar vertebra may drop 
into the pelvic inlet, causing an obstruction in the antero-posterior diameter. 
Backward and downward displacement of the base of the sacrum and the poste- 
rior portion of the pelvic inlet results. Compensatory elevation of the anterior 
portion of the pelvis follows. The height of the symphysis is increased. Thus 
pelvic inclination is markedly lessened, and the vulval orifice is raised and 
directed more anteriorly. The amount of obstruction at the inlet will naturally 
depend upon the distance the last lumbar vertebra descends and the degree of 
lordosis. Frequency and etiology: It is not a common condition. Up to 1892 
Schlesier collected fifty-three cases in skeletons, and many more clinically. It 
is a disease essentially of women, only three cases having been observed in men. 
The etiology is obscure. It is caused by violence, such as blows, excessive body- 
weight, the patients being commonly obese, and the faults of development or 
ossification in the articular portions of the spinal column. The bones are often 
found to be healthy. Clinical characteristics: In most of the cases the anterior 
half of the fifth lumbar vertebra is pushed forward at the same time that the 
posterior part persists in its normal position at the lumbo-sacral joint (Figs. 
872, 873, 874, 875). Now and then a case presents in which the whole ver- 
tebra is pushed forward. There are some cases in which an increased length 
of the vertebra is caused by a separation of the two extremities of the spon- 
dylolytic interarticular part and the space is filled in with fibrous tissue. The 
lordosis is marked (Fig. 874). The diminished pelvic inclination causes an 
undue strain on the ilio-femoral ligaments. In this way .the ischial tuberosi- 
ties are brought closer together than normal, while the crests of the ilia flare. 
Naturally the posterior superior spines of these bones flare also. The ribs 
and the brim of the pelvis become approximated and the height of the 
patient is decreased. The transverse diameter of the outlet is diminished 
while that of the inlet is increased. On internal examination the conju- 
gate diameter of the inlet may be observed to be shortened. Diagnosis: 
This is seldom difficult. The patient has a deformity causing the distance 
from the costal margin to the pelvic inlet to be diminished. There is marked 
lordosis in the lumbar region. The spine of the last lumbar vertebra is more 
easily felt than normally. The transverse diameter of the pelvis is increased 
owing to the flaring of the iliac bones. There is a contraction of the pelvic 
outlet. The contraction of the true conjugate is due not to the sacrum but 
to the lumbar vertebrae. The external conjugate is markedly diminished. The 
patient is rather short, having lost in stature. Neugebauer, in 1895, published 
an article on " Ichnograms " or pictures of foot -tracks. In spondylolisthesis 
the steps are very short, and the legs, being converged, are put forward one in 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 



699 





Fig. 872. — Spondylolisthesis. Poste- 
rior View. — (Budin.) 



Fig. 873. — Spondylolisthesis. Anterior 
View. — (Budin.) 




Fig. 874. — Sagittal Section of a Spon- 
dylolisthesic Pelvis. — (Neugebauer.) 



Fig. 875. — Sagittal Section of a Spon- 
dylolisthesic Pelvis. — (Neugebauer.) 



'00 



PATHOLOGICAL LABOR. 






front of the other. The patient's appearance and history are very important. 
There may be the history of a fall or other accident, or the bearing of heavy 
weights. The buttocks, taken together, are curiously heart-shaped, being flat- 




Fig. 876.— Lumbar Vertebra of Nor- 
mal Shape. 




Fig. 877. — Lumbar Vertebra Elongated 
by Spondylolisthesis. 



tened and ending below in a point. The abdomen is pendulous and deeply creased 
above the symphysis. Looked at from behind, the patient -presents a saddle- 





Fig. 878 and Fig. 879. — Dorso-lumbar Kyphosis. — (Tarnier.) 



shaped back. Her gait is peculiar; she may feel top-heavy. There is some 
times crepitus in lumbar region (Fig. 872). Prognosis: The extent of the 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 



701 



obstruction to labor depends upon the degree to which the pelvic cavity is 
encroached upon by the lumbar vertebras. The effect of this pelvis on labor 

is similar to that of the flat pelvis. Lacerations, 
fistulae, and tears are frequent. As the presenting 
part descends it strikes the middle part of the 
pelvic floor instead of sliding forward to the 
orifice of the vulva. Treatment: A large propor- 
tion of the women die in labor. If the deformity 
is diagnosed and the distance from the nearest 
lumbar vertebra to the symphysis — the false or 
effective conjugate — is 3I inches (7.93 cm.), the 
forceps can deliver the child. If less, a suprapubic 
operation must be done. 




]*$0^ A 



Fig. 880. — Sacro-lumbar Ky- 
phosis. 




Fig. 8S1. — Kyphotic Pelvis showing the Iliac Foss.e 
and Pelvic Inlet. 




Fig. 882. — Diagram of the Pel- 
vic Inlet of Fig. 881. 



8S3 



Kyphotic Pelvis showing the Pelvic 
Outlet. 



Spondylolizema. — The condition known as spondylolizema is analogous to 
the one just described, although it is not congenital but results from caries of 



"02 



PATHOLOGICAL LABOR. 



Fig 




. — Pregnancy with a Kyphotic Pelvis. 
Hanging Belly. — (Tarnier.) 




Fig. 



885. — Oval Oblique Kyphotic Pelvis. 
(Guichard.) 



the last lumbar vertebra. 
The name pelvis obtecta is 
applied to this deformity as 
well as to the extreme rachi- 
tic pelvis. 

II. Kyphosis,* Kyphotic 
Pelvis (Figs. 880 to 883).— 
Breisky gave the first com- 
plete description of this 
pelvis in 1865, although the 
condition had been pre- 
viously recognized by Litz- 
mann and Neugebauer. Fre- 
quency and etiology: although 
this form of pelvis is com- 
paratively rare, still an accu- 
rate observer in the course 
of his practice will undoubt- 
edly meet with examples. 
The deformity results from 
kyphosis or Pott's disease, 
which affects the spine at 
such a low point that the 
usual lordosis which is pres- 
ent as a compensatory fac- 
tor cannot overcome the 
faulty direction of the force 
of the body-weight. Clini- 
cal characteristics: Natur- 
ally the extent of the de- 
formity will depend on the 
position of the spinal pro- 
tuberance (Figs. 879, 880, 
884). The lower this is, 
the worse will be the result- 
ing deformity. The most 
common position for the 
kyphosis is at the junction 
of the dorsal and lumbar 
vertebrae. As the result 
of the insufficient com- 
pensation of the lordosis 
of the lumbar spine, the 
rotation of the sacrum on 
its transverse axis is down- 
ward and backward, just 
opposite to that seen in 
rachitis. The body is bent 

* Kyphosis. Hump-backed. 
Angular curvature and dorsal 
prominence of the spine. Back- 
ward curvature of the spinal 
column. 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 



703 



The sacrum is higher, 
so that its width is 




Fig. 886. — Escape of the 
Head under the Pubic 
Arch in a Kyphotic 
Pelvis. — (Tarnier.) 



forward, and the pelvic inclination diminished (Fig. 884). 
straighter, longer; its lateral concavity is increased 
lessened (Fig. 887). The conjugate of the inlet is in- 
creased. The anterior spines of the iliac bones are 
pushed further apart, while the posterior spines are 
more closely approximated, this latter effect being 
the result partly of the pull exerted by the sacro-iliac 
ligaments and partly of the narrowness of the sacrum. 
The width of the pelvis is decreased through its whole 
depth, most markedly so at the outlet on account of 
the approximation of the spines of the ischia. The 
coccyx and the end of the sacrum are pushed forward, 
thus decreasing the pelvic outlet. The narrower this 
outlet becomes, the wider the inlet, for the outward 
force exerted on the iliac crests is increased, this effect 
being heightened by the extra strain on the ilio-femoral 
ligaments which pull the anterior inferior spines down- 
ward and outward. In order that the body may not fall forward, there occurs 
a slight flexion of the knees and thighs, while there is scarcely any pelvic inclina- 
tion (Fig. 879). When 
the deformity is lumbo- 
sacral there may be in- 
volvement of the superior 
part of the sacrum in the 
pathological process and its 
tissues may be destroyed 
(Fig. 880). The promon- 
tory of the sacrum is pal- 
pated with difficulty per 
vaginam. Diagnosis: The 
history of the case is gen- 
erally plain, and the de- 
formity very evident. As 
in all cases of pelvic 
deformity, the measure- 
ments are most valuable. 
They show that the ante- 
rior spines and crests of the 
ilia are more widely sepa- 
rated, while the posterior 
spines as well as the ischial 
tuberosities are approxim- 
ated. The conjugate of 
the outlet is to some ex- 
tent decreased. Complica- 
tions such as asymmetry, 
general contraction from 
arrested development, and 
lateral contraction at the 
inlet should always be 
guarded against, as they often make spontaneous labor impossible. Prog- 
nosis: Winckel states that in a series of twenty-one cases of this kind the 




Fig. 887. — Diagram showing the Forces Concerned in 
the Production of a Kyphotic Pelvis. — {Tarnier.) 



704 



PATHOLOGICAL LABOR. 



maternal mortality was 66 per cent., while that of the children was 75 per 
cent. Labor is much obstructed by the prominence of the lumbar spine 





— Scoliosis. Poste- 
rior View. 



Fig. 889. — Scoliotic Pelvis, with Encroachment 
of the Left Cotyloid Region upon the Pelvic 
Cavity. 




Fig. 890. — Scoliotic Pelvis. Posterior View. Fig. 891. — Diagram of the Pelvic 

Inlet of Fig. 889. 



in all cases except in those with the least marked lumbo-sacral kyphosis. 
The untoward effects are not generally pronounced until the presenting 
part has reached the pelvic floor (Fig. 886). The tendency to shoulder 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 



705 



presentation on account of the decreased perpendicular diameter of the 
abdominal cavity is generally corrected by the first few labor pains. The 
labor may be more precipitate than normal, but when the presenting 
part reaches the outlet the obstruction may be so great that there can 
be no spontaneous advance, though now and then labor is terminated 
spontaneously on account of the great mobility of the pelvic joints. Occi- 
pito-posterior positions are quite common in these pelves, since on account 
of the posterior deformity of the sacrum more room is offered for the fetal 
back. Treatment: As a rule, labor is not difficult to manage. The forceps 
may afford sufficient aid for delivery; should the case "he .of a grave order, 
symphyseotomy will near- 
ly always suffice. If, how- 
ever, there is present an 
asymmetrical or extreme 
contraction, it may be 
necessary to resort to 
Csesarean section. Incase 
of a dead fetus, craniot- 
omy may easily be per- 
formed, since the head on 
the pelvic floor is quite 
accessible. 

III. Scoliosis.* Scolio- 
tic Pelvis (Figs. 888-891). 
— This term includes all 
the lateral deformities of 
the spinal column having a 
pathological origin. Fre- 
quency and etiology: This 
is a rare form of pelvic 
deformity. The most fre- 
quent cause is rachitis, 
consequently the pelvis 
may be contracted as well 
as asymmetrical. The 
origin, however, may be 
non -rachitic. The de- 
formity, as a rule, begins 
during the development of 
the pelvis, the result de- 
pending on whether this is 
before or after ossification 
of the pelvic bones. Clin- 
ical characteristics: The deformity of the pelvis is marked and the degree of 
scoliosis is quite perceptible. The two sacrocotyloid diameters are not of equal 
length, while the internal conjugate does not come up to the normal. Deformi- 
ties of the pelvis are not so marked as they would be, did not every bend in 
the spinal column usually have its compensatory curve. In the pelvis with 
this deformity there is a certain amount of oblique contraction. The lumbar 
vertebrae are the ones generally affected. The superior articulating sacral 
surface, on the side toward which the bending of the spine takes place, 

* Scoliosis: Lateral curvature of the spinal column. 
45 




Fig. 892. — Scolio-rachitic Pelvis, with Reniform 
Inlet. Encroachment of the right cotyloid region 
upon the pelvic cavity. 




Fig. 893. — Diagram of the Pelvic Inlet of Fig. 892. 



706 



PATHOLOGICAL LABOR. 



receives the greatest weight. The center of gravity is displaced. The head 
of the femur exerts a greater pressure upward, inward, and backward against 
the innominate bone of the deformed side. There is also an anterior upward 
displacement of the acetabulum on this side, while the symphysis is forced to 
the opposite side. The pelvis on the deformed side is diminished in size (Figs. 
889, 890, 891). In case of the limita- 
tion of the scoliosis to the dorsal verte- 
brae, a compensatory bending of the 



Sc.pp.dr. 




Sc.o.l.g. 




Fig. 894. — Scolio-rachitic Skeleton. Sc- 
pr.dr., Primary dorsal scoliosis; Sc.o.l.g., 
compensatory lumbar scoliosis. — (Clamart.) 



Fig. 895. — Kyphoscoliotic Skeleton. 
— (Leopold.) 



lumbar vertebrae may hinder any change in the form of the pelvis from taking 
place. Diagnosis: The deformity may be detected by observation and pelvim- 
etry. Prognosis: The asymmetry is seldom so marked as to cause serious 
obstruction to labor, the mechanism corresponding with that in the generally 
contracted pelvis. If delivery is possible, the forceps is indicated after the 
head has become well moulded. 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 



707 



IV. Kyphoscoliosis.* Kyphoscoliotic Pelvis (Fig. 895). — This deformity 
includes a combination of the malformations of kyphosis and scoliosis. It is 
an obliquely contracted pelvis of lesser degree, being mostly deformed in the 
transverse diameters. Frequency and etiology: The etiology is naturally that 
of the two types which make this combination. Clinical characteristics: The 
most common example of this type 
is the lumbo-dorsal kyphoscoliosis. 
The kyphotic deformity is primary in 
point of time, and, combined with the 
scoliosis, a combination of both sets 
of deformities results with a trace of 
the original funnel-shape. The pelvis 
is decidedly asymmetrical, though its 
lateral contraction is not so great as 
in a pure kyphosis. As the kyphosis is 
etiologically rachitic and not carious, 
it will not be angular, but it will be 
superior dorsal in position and will 
run the chance of being compensated 
for by lordosis of the lumbar region. 
The joints are all rachitic. The sym- 
physis is inclined to the side opposite 
the direction of the lumbar curve. 
The spinal bones present the combined 




Fig. 896. — Assimilation of the First 
Coccygeal Vertebra with the Sa- 
crum. 1, Blending of the horns of the 
coccyx and sacrum; 2, blending of the 
bodies of the fifth sacral and first coccy- 
geal; 3, movable intercoccygeal articula- 
tion; 4, assimilation of first coccygeal 
vertebra; 5, coccyx. 



Fig. 897. — Lordosis from Paralysis of 
the Spinal Muscles. — (Hirst.) 



deformities of rachitis and kyphosis. 
Vaginal examination yields the same 
results as in kyphosis. The true 
conjugate is increased and the pelvis 
is transversely flattened and represents a lesser degree of obliquely contracted 
pelvis. Diagnosis: This will be made from observation of the deformity and 
from pelvic measurements. Prognosis: This will depend upon the degree of de- 
formity. 

V. Assimilation Pelvis. — This pelvis resembles the kyphotic type and is 
slightly funnel-shaped. The deformity depends upon the symmetrical blending 
* Kyphoscoliosis: Backward and lateral curvature of the spinal column. 



708 



PATHOLOGICAL LABOR. 



of the five vertebrae of the coccyx with the lower sacral vertebra or of the 
upper sacral vertebra with the lower lumbar vertebra (Fig. 896). Single- 
sided asymmetry can depend upon scoliosis of the vertebras of the coccyx. The 
deformity then resembles scoliosis and is more pronounced in the presence of 
rachitis. When the deformity is symmetrical, the promontory is high, the 
angle being but slightly developed, and the pelvic curve diminished by the 
slight forward bending of the trunk. 

VI. Lordosis Pelvis.* — Neugebauer refers to some cases of primary lordosis 
independent of spinal disease or pelvic deformity, and in this country the only 
case described is that of Hirst (Fig. 897). It can readily be seen how a marked 
anterior spinal curvature would greatly increase the pelvic inclination, and thus 
interfere with the engagement of the presenting part. 



E. ANOMALIES OF THE PELVIS DUE TO DISEASE OF THE WEIGHT-BEARING 

PARTS OF THE SKELETON. 

I. Coxitis. Coxalgic Pelvis (Fig. 900). — This deformity may be described as 
an oblique pelvis dependent upon hip disease. The coxalgic pelvis is subject 
to several modifications which depend upon the time at which the affection 
originates and mobility of the diseased part as well as upon the presence of 
dislocation. The earlier this trouble 
begins and the more the leg is used, 
the greater will be the deformity. If 




Fig. 898.— Coxalgic Pelvis showing De- 
formity on the Healthy Side. 



Fig. 899. — Coxalgic Pelvis showing De- 
formity on the Diseased Side. 



the disease does not appear till after the pelvis is developed, there may be an ab- 
sence of obliquity. Frequency and etiology: The deformity is not infrequent. 
Other causes besides hip-disease are infantile paralysis, dislocation of the hip- 
joint, and amputation of a lower extremity. Clinical characteristics: There are 
two types of this pelvis, although there is obliquity in each case : (1) In the first 
type the innominate bone on the unaffected side is pushed upward, inward, and 
backward, since the sound leg carries the main body-weight (Fig. 898). Thus the 
sound side is contracted while the diseased side, lacking the normal developing 
forces, persists in its infantile form or the form it had when the disease manifested 
* Lordosis: Anterior curvature of the spinal column. 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 



709 



itself. The location of the deformity is just the reverse of that in the Naegele 

pelvis. (2) In the other type 
the deformity is on the diseased 
side, the innominate bone of this 
side being forced in upon the pel- 
vis the deformity depends upon 





Fig. 900. — Coxalgic Pelvis with Adduction of Fig. 901. — Enlargement of the 
the Diseased Femur (Left Side). Cotyloid Region due to Cox- 

algia. 



the arrested development of this side (Fig. 899). There is probably a co- 
existent atrophy of the sacral ala with anchylosis of 
the sacro-iliac joint. There will be observed, there- 
fore, an asymmetrical pelvis; rotation of the pelvis 
upon the spinal column ; anchylosis of the hip ; and de- 
cided shortening of the conjugate. Diagnosis: These 
patients are recognized by their limp. Pelvimetry 
as well as palpation, both external and internal, 
will reveal the state of affairs in the pelvis. Prog- 



i $&Sip.<i*-.~ 





Fig. 902.— Dislocation of Fig. 903. — Deformed Pelvis from Congenital Disloca- 
the Right Femur. tion of One Femur (Left Side). 



710 



PATHOLOGICAL LABOR. 



nosis: The degree of deformity is seldom so great as to interfere seriously with 
labor. In such a case the method of procedure would correspond with that 
advised for the Naegele pelvis. In the first type there is seldom any serious 
obstruction to labor unless rachitis is also a complication. It is in the second 
type that difficulty is experienced, and it may be as great as in the Naegele 
form. 

II. Luxation of the Head of One Femur (Figs. 902, 903). — If this deformity 





Fig. 904. — Congenital Dislocation of 
Both Femurs. 



Fig. 905. — Congenital Dislocation of 
Both Femurs. 



is congenital or if it take place in early years, the pelvis is somewhat affected, 
but not, as a rule, to such an extent as to affect labor seriously. The resulting 
shape of the pelvis will depend upon the direction in which the luxation takes 
place. An oblique contraction may be produced by a one-sided dislocation. 

III. Luxation of the Heads of Both Femora (Figs. 904,905, 906, 907).— The 
general: statements made in the last paragraph will also apply to this case. If 
both thigh-bones are dislocated backward upon the ilia, the 'sacrum is rotated 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 



711 



forward to an extreme degree, 




and the canal of the pelvis becomes shallow 
with a very wide outlet. The 
line between the lower border 
of the symphysis and the 
inner femoral condyles is 
diminished. 

IV. Unilateral or Bilateral 
Club-foot (Fig. 908).— These 



Fig. 



906. — Pelvis from a Case of Congenital 
Dislocation of Both Femurs. 




Fig. 



907. — Diagram of the Pel- 
vic Inlet of Fig. 906. 



'deformities produce changes of little importance, 
is increased, the arch of the pubis 
is narrowed, the tuberosities of 
the ischia and the acetabula are 
brought closer together. 

V. Absence or Deformity of 
One or Both Lower Extremities. — 
Iii the first case there results the 
"Sitz pelvis," the characteristics 
of which have already been noted 
(page 679). Generally there is 
rotation of the innominate bones 
on an anteroposterior axis, so that 
the iliac crests approach each other, 
while the ischial tuberosities are sep- 
arated. Any deformity occurring in 
consequence of the bowing of the 
extremities is scarcely worth the 
mention from a practical standpoint. 



The inclination of the pelvis 




Fig. 



90; 



Deformed Pelvis from 
Club-foot. 



Double 



GENERAL SYMPTOMATOLOGY. 

Subjective Symptoms. — In pregnancy: The effects of deformed pelves are 
various. They may alter the position of the pregnant uterus ; e. g. , in contraction 
of the pelvic inlet in the early months, the uterus may become retroverted, and 
even finally incarcerated in the pelvis. Later the uterus is higher than in normal 
gestation, since the head of the fetus cannot descend into the pelvis. In the 
later months of pregnancy the uterus is far more mobile than normal on account 
of the narrowing of the pelvis. Its obliquity is also increased. The patient is 
frequently unable to empty the bladder owing to the pressure to which it is 




Fig. 909. 



Fig. 910. 




Fig. 911. 



Fig. 912. 





Fig. 913. 



Fig. 914. 




Fig. 915. 

Figs. 909 to 915. — Shape of the Pelvic Inlet in the More Common Types of 
Pelvic Deformity, Compared with the Normal. 



712 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 713 

subjected. Quickening is felt early, generally by the fourth month. Pendulous 
abdomen is very common in contracted pelvis from the position of the long axis 
of the uterus, which looks either forward or to the right, and is especially marked 
in patients whose abdominal walls are flaccid. It is more frequently found in 
multigravidas than in primigravidas. If pendulous abdomen is not a complica- 
tion, the fundus will be much higher in position than normal. In labor: The 
pains are very irregular and their nature depends upon the abnormal factors 
producing them. They are sometimes violent, at other times spasmodic, and again 
they are feeble. Labor is prolonged. When labor is beginning, the presenting 
part is abnormally high and does not adapt itself well to the lower uterine seg- 
ment. The head is very slow in engaging, consequently in pregnancy lightening 
does not occur, and these conditions give rise to painful dyspnea. Sometimes 
the presenting part fails to engage at all. The caput succedaneum is generally 
very large and its gradual development is sometimes thought to indicate progress 
of the descending part. The presentation and position of the fetus also often 
suffer from contracted pelves, the abnormal varieties being about three times as 
common as normal. For example, a vertex presentation may be turned into a 
brow, face, or shoulder. In breech presentation there is frequently a prolapse 
of foot or knee. Prolapse of the cord is also frequent. Multiparity, as in 
the normal pelvis, only adds to the likelihood of faulty presentations, for the 
walls of both uterus and abdomen became gradually more relaxed with each 
successive pregnancy. If the uterus together with the cervix is either at or 
above the pelvic inlet, the bag of waters is forced downward into the cervix as a 
conical body. Not infrequently the membranes rupture early with escape of 
the liquor amnii. The lower uterine segment may become so stretched and thin 
that it bursts, while the rupture may involve the cervix and vagina or there may 
occur a forcible separation of the uterus from the vagina. In any case the mater- 
nal soft parts are apt to be bruised and lacerated; so much so, indeed, that 
sloughing will often follow. (Edema is also a complication. The articulations 
are in certain cases separated by the force exerted for the delivery of the child. 
Objective Symptoms. — (See General Diagnosis, below.) (Figs. 909 to 923.) 



GENERAL DIAGNOSIS. 

Previous History. — The previous history will often furnish essential infor- 
mation concerning the present condition of the pelvis. If traces of rachitis, 
for example, are seen in other parts of the body, there will be strong presumptive 
evidence as to the presence of a rachitic pelvis. The history of previous labors 
will offer a probable prognosis as to the termination of pregnancy. The char- 
acteristic influences of the various diseases have been enumerated. 

Inspection. — Account should be taken of the posture of the woman, of spinal 
curvature, and of any lameness. 

Palpation. — The position of the hips, the size of the iliac bones, the depths 
of the iliac fossae, the width and curve of the sacrum, and the depth, thick- 
ness, and inclination of the symphysis should be noted (Figs. 909 to 923). 

Mensuration. Pelvimetry. — The physician should measure the pelvis as a 
routine in the examination of pregnancy (see page 152) and in cases of suspected 
maternal or fetal obstruction, for the same reason that he uses percussion 
and auscultation in the diagnosis of cardiac and pulmonary disease. Al- 
though the science of pelvimetry is most important, still the child's birth de- 
pends partly on the size of its head, the degree of its adaptability, the char- 



714 



PATHOLOGICAL LABOR. 



acter of the uterine contractions, and the resistance of the maternal perineum 
and soft parts. It also happens that in two patients with the same size pelves one 





Fig. 916.— Congenital 
Dislocation of Both 
Femurs. 



Fig. 917. — Osteo- 
malacia. 



Fig. 918.— Rachitis. Rela- 
tively Contracted. 



Fig. 919. — Oval Oblique 
Pelvis. 



Figs. 916 to 919. — The Author's Lead-tape Tracings of Various Types of Pelvic 
Deformity, showing Sagittal Sections and Shapes of the Pubic Arches of Each. 

can be delivered spontaneously while the other cannot. However, these facts 
do not lessen the obstetrician's duty in respect to pelvimetry; they merely indi- 




Fig. 920. — Double Oblique 
Pelvis. 



Fig. 921.— Spontaneous 
Dislocation of One 

Femur. 



Fig. 922. — Rachitis. Abso- 
lutely Contracted. 



Fig. 923. — Oval 
Oblique Kypho- 
tic Pelvis. 



Figs. 920 to 923. — The Author's Lead-tape Tracings of Various Types of Pelvic 
Deformity, showing Sagittal Sections and Shapes of the Pubic Arches of Each. 

cate its limitations. (Compare clinical characteristics of various forms of pelvic 
deformity, pages 676 to 711.) 

Prognosis. — (See Individual Varieties.) 



J 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 715 



PROPHYLACTIC TREATMENT. 

Prophylaxis may be instituted at various stages in the history of the mother. 

i. Before Marriage. — In case of the grosser pelvic deformities, in which birth 
by the natural passages would be impossible, one would be justified in advising 
celibacy. If marriage is permissible, however, much might be accomplished 
by influencing the woman or her parents to use some discretion in the choice 
of a husband from the standpoint of disproportion in size. Maternal and paternal 
history: The history of a woman's antecedents, from the standpoint of dystocia 
should' always be investigated, as such history must throw light on the question 
of twin births, fecundity, character of labor, anomalous presentations, etc. 
Skeletal peculiarities are naturally transmitted, and since these concern the 
size of the head and the shape of the pelvis, we should obtain any information 
possible as to the character of the osseous framework of the pregnant woman's 
ancestors. We know that families with large bones tend to bear heavy children. 
This fact of itself has little significance, but should a woman of a small-boned 
stock marry into a large-boned family, some of her offspring might have a 
cranial development out of proportion to the capacity of her pelvis. The 
subject of mental development should also receive consideration, for education 
and native intelligence usually imply an excess of cranial development. Should 
two highly intellectual people marry, the degree of cranial development in 
the offspring might constitute an element of dystocia if the mother's osseous 
development chanced to be light. The question of race is important in this 
connection, because the shape of the head varies much in different races 
of men. The dolichocephalic type prevails alike in the northern European 
and Mediterranean races, and especially in the negro; while the brachycephalic 
skull is predominant in the central zone of Europe. In a widely scattered race 
like the Jews, the shape of the head varies somewhat according to the habitat, 
and it is a matter of common knowledge that intermarriage of races contributes 
largely to maternal-fetal dystocia, since not only the shape of the head but 
the size of the bony framework and the degree of intellectual development 
all are factors in a union of different types of men. In these days of low 
birth-rates and small families, these questions become of prime importance, 
for the dread of dystocia is one of the most powerful incentives to unfruitful 
wedlock. 

2. After Marriage and before Conception. — If a woman with a pelvis which 
will not permit the birth of a viable child is already married, or if the pelvis 
of a newly married woman is contracted to a questionable degree and the husband 
is of another race, or much larger than his wife, or has head measurements 
unlike hers, it may be advisable to avoid conception. In any case the choice 
must lie between foregoing offspring altogether and conception with some 
expedient for avoiding labor at full term. If the woman conceives deliberately, 
much care should be used in determining as accurately as possible the date 
of the fecundating coitus. The subject of avoidance of conception has been 
considered on page 39. 

3. After Conception has Occurred. — Absolute contraction: Much would depend 
here upon the month of gestation at which the advice of the physician is sought. 
If the pregnancy is recent and the pelvis such that natural delivery would be 
impossible, the alternative is between artificial abortion and Csesarean section 
at term. In this situation the burden of choice should be placed on the woman 
and her relatives. If Cassarean section is absolutely refused, pregnancy may 
be . interrupted — the sooner the better. In anything short of absolute pelvic 



716 PATHOLOGICAL LABOR. 

contraction, artificial abortion would not be justifiable. If the pregnancy 
were far advanced in absolute pelvic stenosis, little or nothing would be gained 
by the induction of premature labor in comparison with Caesarean section. 
For artificial interruption of pregnancy, see Part X. Relative contraction: 
Here the patient, whatever the stage of pregnancy, may look forward to a 
fourfold alternative: (i) Artificial premature delivery; (2) delivery at full term 
with dependence upon Prochownik's diet to keep down the size of the fetal 
head; (3) delivery at full term either unaided or with such aid as may be derived 
from Walcher's position, high forceps, or version; (4) delivery at full term 
with the aid of major operations (symphyseotomy, Caesarean section). Natur- 
ally the first two resources are only prophylactic. Artificial premature labor: 
This is also a preventive of dystocia, the only objection being the danger of 
fetal death from immaturity. Injuries from the use of forceps must also be 
recognized. The interests of the child will have to be weighed — induction 
of premature labor versus forceps. As to the mother, the danger is undoubtedly 
greater in dystocic delivery than in induced labor. 

Diet. — The principle of regulating the diet of the pregnant woman for the 
purpose of preventing overgrowth or retarding full development on the part of 
the fetus, and thereby favoring eutocia, has been carried out in a limited way for 
a number of generations; yet this topic is hardly mentioned in the great majority 
of text -books. 

About 1840 the idea of an exclusively vegetable diet for the pregnant woman was pro- 
posed by a London chemist named Rowbotham, who laid special emphasis on the impor- 
tance of fresh fruits, the vegetable acids of which were believed to keep the earthy salts from 
precipitation and thereby to retard ossification of the cranial bones. It is not known that this 
teaching was ever incorporated into or even mentioned in any standard work on midwifery. 
But the idea was in some manner kept alive, perhaps through the vegetarians, and has 
cropped out now and then in the by-ways of medical literature. It is the chief recommen- 
dation of a popular work entitled]' "Tocology " (written by a homeopathic woman physician) , 
which has had an extensive sale throughout the United States. The advocates of this 
vegetarian diet have not been backward in claiming remarkable practical results for their 
hobby, but I do not know that this diet has ever been tested by trained observers in the 
field of obstetrics. Prochownik, who devised the noted regimen to be described later, was 
originally unaware of the claims of vegetarians and others as to priority in the field of antidys- 
tocic dietetics. In 1889 he stated that his researches into literature had failed to discover 
evidence of any rational attempts in this direction. In his latest contribution (1901), how- 
ever, he discusses the vegetarian principle very candidly, and admits that races of people 
who subsist chiefly upon vegetables and fruits bear their children easily; this, too. despite 
the fact that their pelvic conditions are often distinctly unfavorable for eutocic births. 
Moreover, European women, who chance to reside in countries where a vegetable diet is 
imposed by circumstances upon visitors, appear to bear their children with less effort and 
suffering than in their native land. Prochownik also gives due credit to the vegetarians 
for limiting the pregnant woman to two meals a day. There is little doubt that some of the 
good results that have been claimed by the supporters of the n on -nitrogenous diet have 
been brought about in w omen with contracted pelves. The previous histories of the patients 
appear to give color to this supposition, but unfortunately the reporters were not trained 
accoucheurs and pelvimetry was not applied. Moreover, in exploiting the vegetarian diet 
in connection with midwifery, the principle has been confessedly to lessen the difficulties 
of child-birth as a whole, without regard to special causes of dystocia. In virtue of this 
fact I am in position to give Prochownik _ full credit for priority in recommending a special 
diet for women with contracted pelves. This dietetic regimen thereby becomes a competitive 
procedure with induction of premature labor, symphyseotomy, Caesarean section, etc. It 
will be noted that eutocic labors have been claimed as a result of the most dissimilar kind 
of diet. The oldest system allowed fluids in abundance with a general reduction in the 
quantity of all solids. The vegetarians also allow fluids ad libitum, while the solids per- 
mitted are essentially non -nitrogenous. Prochownik bars both fluids and carbohydrates 
save in minimal quantities. In attempting to harmonize these discrepancies, the most 
that can be said is that all the diets impose some self-denial during the latter weeks of 
pregnancy, and that Prochownik's results are the only ones that have any scientific status. 
But Prochownik's diet seems especially calculated to favor eclampsia owing to its relatively 
large proportion of nitrogenous food and small quantities of fluids. This point appears 
to have been ignored in this connection. Opponents of the idea of an antidystocic diet 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. Ill 

claim that women in advanced phthisis and similar cachectic states may bear plump 
children. 

Prochownik's attention was called to the subject by the fearful mortality 
among children born before term, especially in connection with induced labor 
for contracted pelvis; and by his special experience in dieting pregnant women 
who were obese, anemic, etc., with the sole aim of improving the mother. In 
this connection he found that the nutrition of the fetus was modified in a twofold 
manner: first the embryo was enough of a true parasite to obtain nutriment to 
fulfil all the practical ends of healthy metabolism, growth, and vitality; second, 
the restriction in the mother's diet could manifest itself in the child in such par- 
ticulars as a lessened accumulation of adipose tissue, and a slower rate of precipita- 
tion of the earthy matter required for ossification. Observations of this char- 
acter have been reduced to a common truth in biology and the application of the 
diet to women with contracted pelves as a substitute procedure for artificially 
induced premature labor was a consistent and logical advance in the management 
of obstructive maternal dystocia. One of the first problems in imposing this 
diet upon the pregnant woman is to cut down the amount of fluids without the 
collateral provocation of constant thirst. To this end fats and carbohydrates 
are eliminated as far as possible and such articles are allowed as contain a large 
quantity of water, especially green vegetables. The diet * as originally published 
appears to have stood the test of experience without the necessity of subsequent 
modification. It is as follows : 

Breakfast. — A small cup of black coffee, 3.38 oz. (100 c.c); zwieback, or 
bread with a little butter, 4 or 5 oz. (25 grams). 

Luncheon. — Any kind of meat or fish, eggs, green vegetables, salad, cheese. 

Dinner. — Same as luncheon, with the addition of bread and butter 1 to 1} 
oz. (40 to 50 grams). 

Absolutely Forbidden. — Water, soup, potatoes, farinaceous food, sugar, beer. 
Fluids allowed: 10 to 14 oz. (300 to 400 c.c.) red or Moselle wine per diem. 

Prochownik has now employed this diet for the past twelve years, the total 
number of births aggregating 26, while other obstetricians, especially in the 
Netherlands, have brought the total up to 62. 

An analysis of the material which is tabulated by Prochownik in the " Therapeutische 
Monatschrift," August and September, 1901, appears to establish the truth of the following: 
(1) All the mothers bore the diet well after slight initial hardships, principally thirst (espe- 
cially in the corpulent), and repugnance to so much animal food. Both these difficulties 
were mitigated by increasing the allowance of green vegetables. The weight of the woman, 
allowance being made for the growth of the embryo and uterus, remained practically at a 
standstill. (2) All the confinements were relatively easy in comparison with previous labors, 
even in those exceptional cases in which despite the diet the fetus was large and fat at 
birth. (3) All the children were born alive, although the mothers, as a class, had expe- 
rienced still-births. The few cases of asphyxia neonatorum were easily reanimated. As 
far as known, all the children survived the accidents which produce secondary mortality. 
(4) The great majority of the children were lean at birth, there being a notable subdevelop- 
ment of the panniculus adiposus. The skin of the head was noticeably lax and the cranial 
bones exhibited a notable degree of mobility upon one another. (5) The children exhibited 
the essential insignia of maturity (normal length, head measurements, etc.). (6) The nor- 
mal gain in weight took place in the majority of the children. (7) The diet of the mother 
exerted no unfavorable influence upon lactation. 

Naturally, as soon as delivery occurs the special diet is discontinued and 
the substitute regimen is rich in non-nitrogenous articles. In all attempts 
at imposing an antidystocic diet upon a pregnant woman the regimen is not to 
be begun until the latter months of pregnancy. The Prochownik regimen is 

* "Centralbl. f. Gynak.," 1889, No. 33. 



718 PATHOLOGICAL LABOR. 

intended for the last six weeks of gestation only. It is believed that no extra 
advantage would accrue from lengthening the dietetic period. 

Summary of Prophylaxis. — The course of the labor which is in store for the 
patient should be anticipated as far as possible by the obstetrician by all the 
means in his power. There is a great distinction between a primigravida and a 
multigravida, since in the latter there may be a history of previous labors which 
will to a certain extent offer a fair guide to the course of subsequent pregnancy 
and labor. Whether the patient is primigravida or multigravida, the factors 
to be considered are: (i) parental characteristics; (2) palpation of the fetus; 
(3) cephalometry (Muller's test) ; (4) pelvimetry. In inquiring for the history 
of the multigravida, the following subjects should be investigated: (1) The 
number of children already borne; (2) the length of the labors in the separate 
stages; (3) the presentations of the fetuses; (4) the weight of the fetuses; (5) 
the size and shape of the heads; (6) whether a caput was formed and how ex- 
tensive, and (7) the method of birth, whether natural or instrumental. As to the 
child's weight, there is a general rule which holds good: namely, the weight of 
each successive child is slightly increased from the youth of the parents till about 
thirty-five, when it decreases. Naturally, when the patient is a primigravida 
it is far more difficult to anticipate the events of labor. Parental characteristics 
have great influence on the offspring. Large bones in the parents and great 
intellectual development point to a large head in the fetus. When the parents 
are of opposite types, the mother's is most apt to predominate in the child. The 
nutrition of the parents, particularly that of the mother, is an important factor 
in the weight of the child (page 716). Severe manual labor and starvation have 
a tendency to cause premature birth. Expulsion will be effected by the strength 
of the pains, which will depend on the tissues of the mother. If she is weakened 
by anemia, chlorosis, excess of fatty tissue, etc., there will not be the inherent 
strength to cause strong contractions. 

The subject of prophylaxis, therefore, is confined to the following points, 
which are considered in detail. These are: (1) selection of a husband; (2) 
artificial sterility; (3) prevention of conception; (4) artificial abortion; (5) Pro- 
chownik's diet; (6) artificial "premature delivery. 



CURATIVE TREATMENT. 

The problem of the proper management of labor in contracted pelves is one 
of the most difficult in midwifery. The subject itself is a vast one, for it con- 
cerns not only those cases in which the pelvis has been measured and the pelvic 
anomaly diagnosticated, but that greater contingent in which no exact pelvic 
diagnosis is made and which simply represents obstructive dystocia from some 
cephalo-pelvic disproportion which is generally of maternal origin. Broadly 
speaking, these labors can be managed in three ways: (1) Pregnancy may be 
interrupted before the fetus has attained a certain size (Part X). (2) Labor 
at term may be managed along normal lines ; i. e. , may be left to nature until 
some complication arises which threatens the lives of mother and fetus. (3) 
Some form of active intervention, undertaken for the purpose of protecting the 
mother and child from the risks of dystocia, may be practised at or before the 
onset of labor — prophylactic version or forceps, symphyseotomy, embryotomy, 
or Cesarean section. 

1. Custom. — It is a singular fact that precedent and local prejudice play highly 
important roles in the choice of methods. Thus, in one obstetrical center per- 
foration of the fetal cranium appears to be the commonest termination of these 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 719 

labors; in a second, the ideal is symphyseotomy; in a third, expectancy pre- 
dominates; in a fourth, induction of premature labor. Those obstetricians who 
follow the national or local custom in the management of these cases naturally 
offer reasons for their conduct which appear sufficient for its justification. In 
many localities adherence to routine and precedent is responsible for unnecessary 
mortality and morbidity, either fetal or instrumental. 

2. Theoretical Considerations. — Some authorities who are not under the 
influence of custom are actuated largely by theoretical considerations in the 
management of these labors. Such theories may be the outgrowth of personal 
experience. Thus, an obstetrician who has seen spontaneous labor occur re- 
peatedly in moderately contracted pelves without undue prolongation of the 
act of parturition comes to believe that such pelves up to a certain limit are not 
pathological at all. He therefore adopts a let-alone policy in the management 
of these cases. Another practitioner may have seen some accident — a rupture 
of the uterus, perhaps — occur in a pelvis with but a slight degree of narrowing. 
Thenceforth pelvic contraction is always something to be feared, and he forms 
a rule of terminating such pregnancies by the induction of premature labor or 
Caesarean section. 

3. Degree and Kind of Pelvic Contraction. — Many obstetricians try to formu- 
late indications based upon the length of the true conjugate as a clinical index and 
the particular species of pelvic deformity. But even if a uniform scale were agreed 
upon, this method of fixing indications is trustworthy only to a certain extent; 
viz., in determining absolute pelvic contraction, or the degree which is prohibitive 
of delivery by natural passages at term. This, according to Kronig,* is repre- 
sented in a flat pelvis by a true conjugate of 2.76 inches (7 cm.), and in a generally 
contracted pelvis by a true conjugate of 2.95 inches (7.5 cm.). Other obstetricians 
make the degree of absolute contraction slightly lower or higher, but the statistics 
of Kronig show conclusively that a goodly proportion of labors may be sponta- 
neous throughout in any degree of pelvic narrowing which is outside the limit of 
absolute pelvic contraction. The same statistics show that symphyseotomy 
may sometimes be indicated in the very mild degrees of contraction. In other 
words, the differences in the length of the true conjugate, up to a certain point, do 
not furnish a basis for special indications. Other factors are present in sufficient 
force to invalidate any system of procedure based upon several degrees of pelvic 
narrowing. A division into two degrees is well and good, for the indications in 
absolute and relative contraction differ widely. The former may be given in this 
connection. If a woman with absolute contraction becomes pregnant and is seen 
in season, she should be allowed to choose between therapeutic abortion and 
Caesarean section at term. Of other indications it is scarcely worth while to 
speak. If the woman were at the seventh month, it would be possible to inter- 
rupt the pregnancy and perform craniotomy. The Italian school of symphyseo- 
tomists claim to perform their favorite operation in what would be generally 
regarded as absolute pelvic contraction. Delivery of the child by embryotomy 
is, of course, possible in absolute contraction, but the mortality is higher than 
that of Caesarean section. Hence, the problem resolves itself into an alterna- 
tive between abortion before viability and Caesarean section at term. I shall 
consider relative contraction as a whole in endeavoring to describe its manage- 
ment. 

4. Individual Method. — I have implied in the preceding statements that 
every case of labor in a pelvis relatively contracted is a law unto itself, and 
should be managed accordingly, and I hope to succeed in making this 

* "Die Therapie beim engen Becken," Leipzig, 1901. 



720 PATHOLOGICAL LABOR. 

claim good. The first step in a matter of this kind is to study the phenomena 
and results of these labors without disturbing their course. This has been done 
in recent years at the obstetrical clinics of Paris, Vienna, and especially Leipzig, 
where the work of Zweifel and Kronig is of prime importance. 

The Kronig statistics of the latter * show that of 504 cases of labor in flattened pelves 
with a true conjugate between 3.74 and 2.76 inches (9.5 and 7 cm.), intervention for the 
pelvic complication alone was required in less than 9 per cent. (Below 2.76 inches — 7 cm. — 
the percentage of intervention for the pelvic element was, of course, 100 per cent.) In the 
so-called second degree of contraction, 3.35 and 2.76 inches (8.5 and 7 cm.), the percentage 
of intervention for primiparae was but 16, although much higher for multipara?. For the 
so-called first degree of contraction, 3.74 and 3.35 inches (9.5 and 8.5 cm.), the percentage 
of intervention was but 2.7 per cent. In 222 cases of generally contracted pelvis with a 
true conjugate of from 3.94 to 2.95 inches (10 to 7.5 cm.) intervention for the pelvic element 
alone amounted to but 9 per cent. Below the measurement of 2.95 inches (7.5 cm.) (abso- 
lute contraction) the percentage of intervention was, of course, 100. In the second degree 
of contraction alone the percentage of intervention was 16 per cent., and in the first degree, 
zero In other words, in 91 per cent, of these relatively contracted pelves labor was of the 
normal type. In the great majority of cases no intervention whatever was required. In a 
small minority — 14 per cent. — complications arose which menaced the life of the mother or 
child and necessitated the use of the forceps. These complications, however, had no connec- 
tion with the pelvic deformity, at least so far as the mother was concerned, but arose from 
such conditions as fever, eclampsia, placenta prasvia, etc. Indications to terminate labor 
proceeding from the state of the fetus may or may not have been due to the pelvic contrac- 
tion. Doubtless there was a greater proportion of prolapse of the funis and intrauterine 
asphyxia than in labor in normal pelves, but the average duration of labor in these cases was 
less than fifteen hours, which is within normal limits. In the absence of good control 
material it is difficult to prove that the size of the pelvis is responsible for the fetal indica- 
tions for forceps in Kronig's cases. The children were, as a rule, of large size in these forceps 
cases. Of the 64 cases in which it became advisable to interfere, 25 children were saved 
and 39 lost, the latter number including cases of fetal death in utero. The combined fetal 
mortality of the labors of "normal type" was 44, or about 10 per cent. This figure, how- 
ever, is believed to represent the normal fetal death-rate including primary and secondary 
mortality. Kronig and others who incline to the belief that labor in contracted pelves is 
physiological up to a certain point, admit that the size of the pelvis contributes to the death 
of the fetus in certain cases. But no control statistics of labor in normal pelves are pub- 
lished, and as the average duration of these labors is not beyond the normal, it is possible 
that this concession is not warranted by the facts. The proportion of forceps cases is not 
greater than in many miscellaneous series. 

But while statistics thus show that the great majority of these labors may be 
termed physiological, they also demonstrate that even in relative contraction 
spontaneous delivery may be impossible, and that there is no criterion by which 
the obstetrican may foretell the outcome of a case. In something like 6 per cent, 
of cases of labor in contracted pelves, irrespective of the pelvic measurements, 
labor could not be completed without resort to Caesarean section, symphyseotomy, 
or embryotomy. It is fair to assume that in this minority of cases there was 
either absence of proper pains or defective head moulding, and that these ele- 
ments rather than a particular degree of pelvic contraction were chiefly respons- 
ible for the dystocia. In other words, given sufficient plasticity of the head and 
strong uterine contractions, relative contraction of the pelvis does not necessarily 
mean dystocia. 

The management of labor with relative contraction of the pelvis may be 
summed up as follows : Labor should be allowed to proceed and the character 
of the pains and the moulding of the head noted. In vicious presentations and 
positions it may be necessary, of course, to perform prophylactic version. If 
labor progresses satisfactorily, the case may be left to nature unless an indica- 
tion arise to terminate it rapidly. If it becomes evident that labor is making 
no progress, the obstetician must choose between forceps and version, symphy- 
seotomy, Caesarean section, and perforation. 

* Loc. cit. 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 721 



GENERAL CONCLUSIONS. 

The management of obstructive dystocia due to pelvic deformity must 
necessarily assume one of seven types, namely: (i) Therapeutic abortion; 
(2) reduction in the size of the head by (a) Prochownik's diet and (6) the induc- 
tion of premature labor; (3) purely expectant treatment; (4) forceps and version; 
(5) enlargement of the birth canal by (a) Walcher's position, (b) symphyseotomy, 
(c) Caesarean section; (6) all idea of a live birth by the natural passages being out 
of the question, the child is delivered by laparotomy, either by the Caesarean or 
Porro operation; (7) all idea of a live birth by any method having been aban- 
doned, embryotomy is performed within the limits of this operation. 

1. Therapeutic Abortion. — Therapeutic abortion may be cited as an operation 
of choice in the management of dystocia. (See Part X.) 

2. (a) Prochownik's Diet; (b) Induction of Premature Labor. — For Prochow- 
nik's diet, see page 716. (6) Induction of premature labor: In multiparas the 
previous experience of the patient is important. Severe operations may thus be 
avoided. Some previous difficult labors, however, may have been due to faulty 
presentations or positions. It is not at present possible to judge with accuracy 
of the comparative size of the fetal head late in pregnancy, so that the advisabil- 
ity of inducing premature labor is not easily made clear (page 186). All methods 
of determining the relative size of the fetal head and the pelvic inlet are, as yet, 
more or less incomplete and uncertain. (See Methods of Perret and Muller, page 
187.) Bulius (a pupil of Hegar) advises induction of premature labor when the 
true conjugate is 2.76 to 3.15 inches (7 to 8 cm.); Tarnier, Budin, and Bonnaire 
say 3.35 to 2.95 inches (8.5 to 7.5 cm.). Leopold gives as the low limit at which 
the induction of premature labor is permissible in a flat or rachitic pelvis a 
true conjugate of 2.76 inches (7 cm.), and in those generally contracted as 2.95 
inches (7.5 cm.). Some writers (Fehling, Schauta) demand even more room 
before they will permit labor to go to term. B. Pinard concludes that since the 
biparietal diameter in an eight months' child is 3.15 inches (8 cm.), in a seven 
months' 2.76 inches (7 cm.), and in a six months' 2.36 inches (6 cm.), if the con- 
jugata vera is 3.35 inches (8.5 cm.) then labor should be induced at or just before 
eight and a half months, etc., down to 2.76 inches (7 cm.). My rules for the 
induction of premature labor are set forth under Obstetric Operations, Part X. 
Dohrn's statistics give 55 or 60 per cent, of surviving children when labor is 
induced, while the same class of cases left to nature gives only from 10 to 13 per 
cent, of surviving children. There is no doubt that premature children weigh- 
ing from 3 J to 5 pounds (1600 to 2250 grams) have decidedly fewer chances of 
survival than children born at term. 

3. Purely Expectant Method. — It has been claimed * that in moderate degrees 
of pelvic contraction the results of expectancy in the management of labor com- 
pare very favorably with those of delivery in normal pelves. This offers ex- 
pectancy as a legitimate resource in moderate degrees of pelvic deformity. 
When the true conjugate is over 2.76 inches (7 cm.) in a flat and 2.95 inches 
(7.5 cm.) in a generally contracted pelvis, the possibility of the birth of a full- 
term average child must be remembered. If the fetal head is abnormally large 
or the pains are weak and inefficient after the membranes have ruptured, or if 
the head does not engage in the pelvis in spite of vigorous pains, operative assist- 
ance is required. 

4. Forceps; Version. — To expectancy we may add, according to the indica- 
tion, forceps extraction or version with manual delivery. These measures have 

* Valency, Paris, 1900. 
46 



722 PATHOLOGICAL LABOR. 

often been sufficient to overcome considerable degrees of dystocia. Forceps 
operation is applicable to those cases in which the head is engaged or can be made 
to engage by suprapubic pressure, or in which it is possible to be sure that there is 
no disproportion between the head and pelvis. In all cases, as a general rule, an 
attempt at the high forceps operation should be made before any more severe 
operation is undertaken. It is also a good plan, before doing any operation, to 
attempt to assist delivery by the judicious use of anesthesia and the Walcher 
position; too much, however, must not be expected of this last manceuver. 
The forceps possesses the advantages of permitting a great degree of traction 
and a gradual extraction of the head. Its disadvantages are (i) that pressure 
over one diameter increases the length of the opposite; (2) the instrument oc- 
cupies a certain space in the already small pelvis. Version has for its advantages : 
(1) the diameters of the head are not increased by a foreign body; (2) the wedge 
shape of the after-coming head adapts better to the inlet than the shape of the 
fore-coming head. Its disadvantages are : (1) no great force can be exerted upon 
the fetal body or neck; (2) rapid extraction, ten minutes at the longest, is neces- 
sary to secure a live child; (3) the complications of extension of the head and 
arms are always liable to occur, seriousl} 1 - affecting the prognosis. 

5. Walcher Posture; Symphyseotomy; Vaginal Caesarean Section. — We have 
three resources for enlarging the pelvic diameters or overcoming the resistance 
of the soft parts, namely : (1) Walcher's position, (2) symphyseotomy, and (3) 
Duhrssen's vaginal Caesarean section. (See Part X.) Perineal incision may some- 
times be required. Symphyseotomy is an easy operation, but the after-treat- 
ment is difficult and uncertain and stormy convalescence often occurs. It gives 
favorable results for both mother and child when the diagonal conjugate is 3.35 
inches (8.5 cm.) or over. 

6. Laparohysterectomy; Laparohysterotomy. — The situation may require 
laparohysterotomy (Caesarean section, Part X) or laparohysterectomy (Porro- 
Caesarean section, Part X). Both symphyseotomy and Caesarean section give 
such good results in regard to the mother that either operation may be selected 
in the interests of the child in appropriate cases, but in unfavorable cases it is 
better not to endanger the mother's life to save the child but to wait for a future 
pregnancy and secure a living child by inducing premature labor. When the 
true conjugate is 2.36 inches (6 cm.) or less, Caesarean section is the only opera- 
tion, whether the child is living or dead. 

7. Perforation; Cranioclasm ; Cephalotripsy. — Finally we have the various 
mutilating operations — perforation, cranioclasm, cephalotripsy, and embry- 
otomy. Craniotomy on the living child should be done only in the presence of 
great danger to the mother, and when, owing to unfavorable surroundings, the 
danger from symphyseotomy or Caesarean section would be great. The life of the 
child should be considered as much as possible, especially in view of the increas- 
ingly favorable statistics of these two operations. When the child is dead, 
perforation is often a very useful operation, unless the conjugate is so low as to 
demand some other operation. (Part X.) 

Combined Methods of Treatment.— It is difficult to conceive of a case in which 
at least two of these measures could be made to co-operate. Some of these pro- 
cedures are so simple that they could be used in routine, such as the plain expect- 
ancy and Walcher's position. Some must be employed without previous deliber- 
ation ; in other words, they belong purely to the domain of emergencies. Finally 
others are essentially deliberative or elective procedures, requiring foresight, time, 
and painstaking for their accomplishment. Here belong Prochownik's diet and 
the induction of premature labor, and the elective Caesarean section. But however 



MATERNAL DYSTOCIA FROM OBSTRUCTED LABOR. 723 

competitive these resources seem, they may be frequently combined in practice; 
in fact, very few of the methods absolutely exclude resort to some of the others. 



RESUME OF TREATMENT. 

The principles just enunciated are believed to be thoroughly sound for the 
management of labor in contracted pelves. Absolute contraction requires the 
timely induction of abortion or Caesarean section at term. Relative contraction 
requires that labor be induced prematurely if the woman has a bad parturient 
record, but that when she is already at term the case would better be allowed to 
proceed spontaneously until some indication arises for intervention. These 
cases may terminate without aid or with the aid of forceps or version; but a 
higher degree of intervention may be necessary before delivery occurs, such as 
symphyseotomy. Unfortunately such rules are too general in scope to meet 
many of the exigencies of practice, and furthermore are adapted rather to men of 
large experience than to the beginners and occasional practitioners of obstetrics. 
I therefore append my methods of procedure, which are modifications of those 
of Auvard. 

i. Unmarried. — If the physician is consulted as to the marriageability of a 
woman with contracted pelvis, in the presence of absolute contraction he should 
discourage the marital relation. The woman may marry, however, with a clear 
understanding of the consequences of pregnancy. In case of relative contraction 
marriage may be permitted. 

2. Married but not Pregnant. — In absolute contraction, pregnancy must be 
forbidden. In relative contraction, pregnancy may be permitted if the woman 
is favorably situated. 

3. Married and Pregnant. — In absolute contraction pregnancy may be inter- 
rupted if the case is seen in season; otherwise we must wait till term for the sake 
of the child, with Caesarean section an indication of necessity. In the first in- 
stance, however, the patient may choose between therapeutic abortion and 
Caesarean section at term. In relative contraction much will depend upon the 
conditions. Unfavorable conditions include the history of dystocic labors, 
superior size or different race of husband, remoteness from trained attendance, 
a certain degree of pelvic contraction, weak musculature, etc. When so many 
chances are against the prospective mother, the indication of choice is artificial 
premature delivery. But when all the opposite conditions prevail, as with resi- 
dents of large cities, where expert advice, hospitals, and nurses are available, 
with not too high a degree of contraction, it seems advisable for the sake of the 
child to let the pregnancy go to term and carefully supervise the labor, interfer- 
ing at the time and in the manner indicated by circumstances. If the conditions 
are partly favorable, the mother should be given the benefit of the doubt. 
Favorable conditions include the benefit obtainable from Prochownik's diet 
during the last six or seven weeks of pregnancy, while an experienced obstetrician 
could form some idea of the relation between the fetal head and the pelvis by 
the practice of Miiller's manceuver or by Perret's method of cephalometry (page 
187). If the mother has a mortal disease, as diabetes, cancer, which will soon 
end her days, while the child is thriving in titer 0, Caesarean section should be 
performed at term. 

4. In Labor. — If the patient with relative deformity is seen for the first time 
in labor, or if a case has been allowed to go to term, delivery may end spontane- 
ously, or the degree and kind of dystocia may be sufficient to justify the aid of 
the forceps or the practice of version. The latter is indicated in shoulder pres- 



724 PATHOLOGICAL LABOR. 

entations, so common in contracted pelves, and also when the head cannot be 
made to engage. Otherwise the forceps should be applied. If it become appar- 
ent that the fetus can never be extracted alive through the maternal passages, 
symphyseotomy may be performed if the conditions are favorable and the 
true conjugate is 3 inches (7.5 cm.) in length; otherwise the choice must be be- 
tween Caesarean section in the presence of a living fetus and embryotomy when 
the fetus is dead. 



MATERNAL DYSTOCIA FROM GENERAL MATERNAL CONDI- 
TIONS. 

XXII. LABOR IN ELDERLY PRIMIPARAE. 

Definition. — An elderly primipara is one who is thirty years of age and up- 
ward. Some authorities would even make twenty-eight years the boundary- 
line, while others regard thirty-two as the proper limit of youth. 

Etiology. — The causes of late primiparity by no means coincide with late 
marriage. They are to be sought in part in uterine malpositions, metritis, cer- 
vical catarrh, tumors, congenital malformations, sexual frigidity, also in inabil- 
ity of the husband to procreate. The condition of the woman of which she is 
most conscious and which influences her against matrimony is contracted pelvis. 
When, as often happens, this is due to rickets or some skeletal deformity, she is 
not sought in marriage during the age at which men pay attention to externals 
in selecting brides. Sooner or later, too, these women learn something about con- 
tracted pelves, and therefore fear conception. The causes of the prolongation of 
these labors are described under "anatomical rigidity of the cervix" and 
"rigidity of the vagina, vulva, and perineum." 

Symptoms. — After an elderly primipara conceives, her pregnancy and labor 
may exhibit certain peculiarities. Twin pregnancy appears from statistics to be 
common among these women. There is a higher proportion of malaise and gas- 
tric disturbance in the elderly. Kleinwachter thinks that the tendency to pla- 
cental hemorrhages is less marked. The same author found a high percentage of 
renal mischief in those above thirty-five, while there is testimony from numerous 
sources that eclampsia is more frequent. In regard to the duration of labor, 
Courtade obtained an average of twenty-two hours and twenty-seven minutes. 
Nearly nineteen hours of this time was consumed in dilatation. As intervention 
was practised in a number of cases, the results, after eliminating the latter, 
showed about sixteen and a half hours for the entire labor, and fourteen and three- 
quarters hours for dilatation alone. After the further elimination of some pre- 
mature cases, Courtade decides that the average duration of labor in the elderly 
is sixteen hours ; his cases begin at the age of twenty-eight. Ahlfeld, with whom 
the age of elderly primiparity does not begin till thirty-two, finds the average 
duration of labor to be twenty-seven hours ; while Kleinwachter makes the figure 
eighteen hours. In 30 spontaneous labors after the thirtieth year I found the 
average duration of labor to be fifteen hours and forty-nine minutes. There are 
no known modifications of the third stage of these 'labors with the exception, 
according to some, of a tendency to adhesion and retention of the placenta. As 
might be expected, lacerations of the birth tract are more common in the elderly, 
amounting to 30 per cent. Statistics readily show that the proportion of cases 
of operative interference increases with age: thus, from thirty to thirty-five, 13.6 



MATERNAL DYSTOCIA FROM GENERAL CONDITIONS. 725 

per cent.; over thirty-five, 14.58 per cent.; jointly, 14.2 per cent. In regard to 
children, the tendency of the elderly primipara is to produce more boys than 
girls. The average weight of the newly born is, according to Mangiagalli and 
Kleinwachter, less than that of children of young primiparae. The tendency to 
vicious presentation is greater with the advance of age of the primipara; I found 
6 per cent, in 47 cases. Finally, the child mortality is said to be much higher. 
The figures range from 14.24 per cent. (Courtade) to 44.8 per cent. (Cohnstein). 
In my 47 cases the maternal and fetal mortality was nil. I append the private 
statistics of Courgenon, obtained from a study of all labors in women over thirty 
at the Clinique Tarnier, 189 8- 1899, as well as my own material. 

In the Clinique Tarnier of Paris, of a total number of in cases, 81 ended spontaneously 
(73 per cent.) and the remainder were terminated with forceps. Post-partum hemorrhage 
occurred in 8 per cent. The average duration of labor was seventeen hours thirty minutes. 
There were about 5 per cent, of vicious presentations and 8 per cent, of pelvic deformity. 
Uterine inertia was present in 19 per cent. About 6 per cent, of women had albuminuria, 
but none developed eclampsia. There was one case of placenta praevia. The maternal 
mortality was less than 2 per cent., the fetal less than 4 per cent. In 2200 cases of labor I 
found the total number of elderly primiparae to be 47, of which 30 ended spontaneously 
(63.8 percent.); the remainder terminated with forceps. Four patients (8.5 per cent.) 
had post-partum hemorrhage. The average duration of spontaneous labor was fifteen 
hours forty-nine minutes. There were about 6 per cent, of vicious presentations and 25 per 
cent, of pelvic deformities. Uterine inertia was present in but 4 per cent.; if, however, we 
reckon the cases of post-partum hemorrhage under inertia, the percentage is nearly 13. 
There were no cases of placenta praevia. The maternal and the fetal mortality was eacho. 

Conclusions. — The statistics of Courtade, of Courgenon of the Tarnier Clinic , 
and the author's own material appear to show that labor in elderly primiparae is but 
slightly longer on the average than in primiparae in general. Normal labor with 
first-born children is computed to last from twelve to fifteen hours (Tarnier). In 
the author's material the average duration was fifteen hours forty-nine minutes — 
only some twenty minutes less than in the elderly alone. Hence the duration 
obtained by Ahlfeld and others (twenty-seven hours, twenty-five hours, etc.) can- 
not be attributed to mere age. Again, the low maternal and fetal mortality of 
the Tarnier Clinic and my cases show that the heavy mortality of certain 
statisticians (14.2 percent., 44.8 percent.) should be attributed neither to the age 
of the parturients nor to the instrumental intervention. The most, then, that 
can be said of the influence of age on primiparity is that it slightly prolongs the 
first stage of labor and somewhat increases the frequency of indications for the 
use of the forceps. The same conclusion is also reached by Courgenon. This is, 
of course, opposed to the tradition which prevails in both medical and lay circles 
and also appears to discredit the existence of what is known as "anatomical 
rigidity of the cervix," which is believed to be almost uniformly present in elderly 
primiparae (page 664). Tarnier and Budin hold that the condition of absolute 
undilatable cervix, which sometimes gives way to circular rupture rather than 
yielding naturally, is excessively rare, and not to be confounded with the rigidity 
which is almost universally present in the primipara, and even in the multipara 
in premature labors. The coincidence of extreme anatomical rigidity in a few 
labors in elderly primiparae might well beget the impression that such an associa- 
tion was inevitable, but, as has been shown, there is no sound basis for such an 
opinion. What were the real causes of the extreme duration of labor and the 
high maternal and fetal mortality registered by competent observers in connection 
with primiparity after thirty years of age ? Possibly the mothers were influenced 
unfavorably by the belief in the fatal issue of such labors. The problem is an 
important one, for in an era of late marriage and low birth-rate many women 
avoid maternity on the ground that they are too old for bearing children without 



726 PATHOLOGICAL LABOR, 

great hazard to themselves. It is known that for some reason late breeders 
possess a higher proportion of pelvic deformity than younger women. I found 
25 percent, of pelvic deformity in my 47 cases of elderly primiparity. 



XXIII. INTESTINAL HERNIA. VAGINAL HERNIA. 

The ordinary forms of hernia — inguinal, crural, and umbilical — can hardly 
be ranked among causes of maternal dystocia. On the other hand, there is a 
special type of hernia — namely, the vaginal — which should be enumerated among 
such causes. Here the usual course of the prolapsed intestine is to occupy 
Douglas's pouch, although in rare instances it may descend in front of the uterus. 
The gut may remain in Douglas's cul-de-sac or descend between the vagina and 
the rectum. In the latter case it may appear at the perineum or in one of the 
labia majora. For vaginal hernia to occur, some anomaly of form of Douglas's 
cul-de-sac should furnish a predisposition. Such anomalies may be produced by 
a prolapse or retroversion of the uterus which tends to stretch the retrouterine 
ligaments. The accident, essentially rare, occurs much more frequently in the 
multiparous. Vaginal hernia may consist of both intestine and omentum. In 
the rare anterior form the hernia may comprise part of the bladder. These 
hernias seldom cause symptoms during gestation. In a few rare instances the 
size of the mass has been known to cause obstructive phenomena affecting the 
rectum and bladder. In a few cases rupture of the sac has been known to occur 
before delivery. From the standpoint of dystocia, vaginal hernia, if large, offers 
some hindrance to the descent of the head; but the danger concerns the mother 
principally, since the prolonged compression of the hernia may terminate in 
strangulation and necrosis of the gut. Diagnosis should be easy. If in the 
course of digital examination the finger encounters a bulging, elastic mass 
in the posterior cul-de-sac, and if this tumor is reducible, there can be little 
doubt as to its nature. Nevertheless, vaginal hernia has been mistaken for 
a great number of conditions, including the bag of waters, rectocele, cyst of 
the vagina or ovary, etc. If the hernia has made its way to the labium majus and 
the fact of intestinal protrusion is recognized, the physician will naturally be- 
lieve it to be an inguinal hernia. In such a case Stoltz's test should be 
applied as follows : The hernia is reduced, the inguinal ring closed by the thumb, 
and the woman instructed to cough; if now the tumor reappears in the labium, 
an inguinal hernia may be excluded. The hernia is now reduced for the second 
time and a finger in the vagina compresses the latter against the ischium on 
the side of the hernia. If the patient coughs now, the hernia does not reap- 
pear. Treatment: If the diagnosis of vaginal hernia is made early enough in the 
course of the labor, the indication is to reduce the hernia and hold it back until 
the descent of the head into the vagina prevents any further probability of pro- 
lapse during labor. To reduce the hernia it may be necessary to apply the taxis 
under an anesthetic ; although the knee-chest position may answer in some cases. 
Conjoined manipulation (abdominovaginal and vagino-rectal) may in certain 
cases serve for the reposition. In irreducible hernia during labor the indica- 
tion is to terminate the latter with all haste after dilatation has occurred. 



MATERNAL DYSTOCIA FROM GENERAL CONDITIONS. 727 



XXIV. CARDIAC AND PULMONARY DISEASE. 

Asystole in Labor. — The bearing of organic heart disease upon marriage, 
pregnancy, and the interruption of gestation has already been considered 
(page 368). If a patient in whom the disease has passed the period of com- 
pensation should become pregnant and go on to term, death is pretty cer- 
tain to happen during delivery. Neumann * publishes a case of this sort and 
cites a number of similar instances. Under these circumstances, however, it 
has been possible to save the child's life by rapid forceps extraction. (See Coffin 
Birth, page 728.) If the woman is not dead but nearly moribund when the 
physician reaches the lying-in chamber, it is still possible to rescue her, as shown 
by a case cited by Neumann. The patient, six months pregnant, was asystolic, 
presenting anasarca, ascites, and orthopnea. She was held in a nearly upright 
position by several attendants for some hours, or until the cervix could be dilated 
and the child perforated and extracted. She recovered from the asystole. In 
labor with organic heart disease properly compensated, the indications do not 
vary from those which obtain in delivery under normal conditions. It has been 
claimed that the rapid fall in the intra-abdominal pressure which follows the 
emptying of the uterus in these cases may lead to death post-partum; to lessen 
the danger a sand-bag can be placed upon the abdomen after delivery. 

Pulmonary Disease. — Acute obstruction of the larynx from any cause may 
bring on labor, and under these circumstances the fetus is likely to perish from 
asphyxia in utero. Tracheotomy is indicated in the interest of both mother 
and fetus. If after tracheotomy the mother is moribund, Caesarean section 
may save the child. If pneumonia coexists with labor, the cardiac insufficiency 
which accompanies this disease may lead to acute pulmonary oedema and death. 
If labor is impending during pneumonia, efforts should be directed to securing 
delay. After labor is under way it should be hastened with all due speed. 

XXV. CEREBRAL AND SPINAL DISEASE. 

The severe forms of neuroses, such as epilepsy, hysteria major, and the grave 
form of chorea gravidarum, appear to exert but little influence on the labor. 
Meningitis has sometimes occurred in pregnancy either with or without erysipelas. 
When labor begins, convulsions develop. Cases of labor complicated with chronic 
spinal diseases are on record. One case is recorded in which there was a chronic 
myelitis of the whole cord with paraplegia and anesthesia extending as high as 
the umbilicus. The mother suffered no pain. In tabes dorsalis the course of 
labor is normal in the great majority of cases. 

Delirium or Insanity of Labor. — In very sensitive patients the natural 
suffering and restlessness incident to labor may pass into a state of transient 
fury, the explosions occurring during the pains. These women tear their hair, 
beat the wall, and indulge in furious cursing. This acute psychosis is especially 
noticeable in unmarried women, as I have observed numerous cases at the 
Emergency and New York Maternity Hospitals among this class of patients. 
After delivery the patient has no recollection of this state of mind. Technically 
this condition is an acute delirium and not true insanity. The treatment is 
based upon general principles. 

* " Centralbl. f. Gynak.," March 10, 1900. 



728 PATHOLOGICAL LABOR, 



XXVI. DIGESTIVE DISTURBANCES. 

Pernicious Vomiting. — Under certain circumstances labor may be much 
disturbed by pernicious vomiting. The causes comprise actual organic disease 
of the stomach and functional disturbance from errors in diet. The determining 
cause of a paroxysm of vomiting is a severe labor pain. The coincidence of 
labor and vomiting is not unusual in anemic primiparae. Mental emotion is also 
a cause. As this vomiting may presage the development of eclampsia or some 
other affection, it is best to terminate labor at once. Hematemesis may occur 
during labor when gastric cancer or ulcer is present, but it does not constitute 
an indication for hastening delivery. Rupture of the spleen sometimes occurs 
during labor and always ends fatally. 



XXVII. SUDDEN DEATH DURING LABOR. 

Sudden death may occur during parturition from a great variety of causes. 
Predisposing causes may exist before labor, the latter acting as a determining 
cause ; or the death may be the termination of a condition produced by pregnancy 
itself, (i) The predisposing causes independent of pregnancy: (a) Circulatory 
— valvular heart disease, rupture of a diseased aorta, hydropericardium, fatty 
heart; (b) respiratory — suffocation during labor from presence of a goiter, pres- 
ence of hydrothorax; (c) digestive, etc. — rupture of spleen; (d) cerebrospinal 
— cerebral apoplexy. (2) Predisposing causes as a consequence of pregnancy: 
(a) Eclampsia; (b) hemorrhage, as from placenta prasvia, precocious detach- 
ment of a normally seated placenta, rupture of the uterus, or of varicose veins in 
the broad ligament; (c) entrance of air into veins; this accident occurs in pla- 
centa praevia, cancer, rupture of the uterus, and in manual and instrumental 
intervention. (3) Unknown causes of death. Death has occurred suddenly 
from the mere introduction of the hand into the vagina for the purpose of per- 
forming version. (4) Shock. (See Part VII.) (See Sudden Death in the 
Puerperium, Part VII.) 



XXVIII. POST-MORTEM DELIVERY— COFFIN BIRTH. 

Post-mortem parturition acquires its obstetrical and medico-legal importance 
from the possibility of physicians and midwives — the latter particularly — being 
made defendants in suits for malpractice on the ground of the delivery of the 
child after the death of the mother, and on the contention that this accident was 
preventable and due to lack of skill or to ignorance on the part of the practi- 
tioner. The case reported by Moritz * is the best illustration to be found of this 
charge. Three theories, according to Aveling,| have been advanced in explana- 
tion of the phenomenon. The first is that it is caused by the contraction of the 
uterine walls in rigor mortis. This seems hardly worth consideration, for the 
contractions are not sufficiently powerful to overcome the natural obstacles 
to the passage of the child, with the superadded narrowing and rigidity of the 
parturient canal from the same cause. The second theory is the pressure of the 
putrefactive gases in the abdominal cavity, acting on the point of least resistance, 

*Moritz: " Vierteljahresschrift f. gericht. Med.," p. 93, Bd. v, 1893; also Bleisch: 
" Vierteljahresschrift f. gericht. Med.," 1892, Bd. in, p. 38. 
fTrans. Obstet. Soc. London, xiv, p. 240, 1872. 



MATERNAL DYSTOCIA FROM GENERAL CONDITIONS. 729 

expelling the fetus and pushing the uterus before it until it lies outside the 
genitals distended with foul-smelling gaseous products.* There can be no doubt 
that this explanation is the true one in a majority of instances, but there still 
remains a class of cases which it will not explain, since the birth took place too 
early for decomposition to have advanced so far as to produce sufficient pressure 
of gas. To cover this ground a third cause has been proposed in the conservation 
of power in the uterine muscle for some time after death (two hours is the limit 
generally placed). This contractile irritability preserved after death has been 
noted by various writers. Fodere f says that "the uterus may expel the fetus 
after death, its organic action being conserved after dissolution has taken place." 
BaudelocqueJ found the uterus contracted after the lapse of a few hours in a 
woman whom he had delivered immediately after death. Arbeiter \ found a 
like condition of affairs, delivery of the child having been accomplished by 
version and extraction three-quarters of an hour after death. During the 
operation the uterus was flaccid, but it contracted later into a hard ball. Leroux || 
cites a case of the same character, and others are on record. The uterus is often 
said to be the last portion of the body to lose its power of contraction and the 
last also to undergo decomposition. It is possible, then, to believe that when 
birth occurs within a few hours after the mother's death, the force retained in the 
voluntary muscles of the walls of the uterus is sufficient to complete the labor. 

Dr. W. W. Rangeley, of Christainsburg, Virginia, in a personal communication, has 
kindly furnished me with the following case of coffin birth: Upon May 7, 1901, Mrs. J. Vaden 
died suddenly, and after the usual interval was buried, she being at the time of her death 
ten months pregnant. All the parties present at the time the body was placed in the coffin 
testified that at that time there was no evidence of birth. Subsequently the husband was 
suspected of having poisoned his wife, so on May 18, 1901, the coffin was opened in the pres- 
ence of a coroner's jury, and the body examined by Drs. Rangeley and M. B. K. Linkous. 
The abdomen was partly distended with gas so as to resemble pregnancy, and it was the 
first impression that the fetus had not been born. Incision of the abdomen caused it to 
collapse, and then search was made for the child, which, with cord and placenta attached, 
was found well down under the thighs. The child weighed nine and a half pounds and was 
dead. The uterus was, unfortunately, not examined. The body was in a state of decomposi- 
tion, but the fetal cadaver was well preserved. The cord was strong enough to sustain the 
weight of the placenta when suspended. The opinion of the physicians present was that the 
intra-abdominal gas pressure expelled the fetus after the effects of rigor mortis had subsided. 

Can the Fetus Live After the Death of the Mother? — While we may be per- 
mitted a doubt in such a case as that of Reiss,** in which, according to that 
author, a day passed before a living child was born, the answer to the question must 
be in the affirmative when the interval is only an hour or less. In the discussion 
of Aveling's paper, Dr. Madge ft stated that he had observed fetal movements 
after death in several cases and wished to extract the child by Caesarean section 
but was not permitted. Brunton %% after a quarter of an hour extracted a living 
child from the mother's corpse. Buffon and Shierig have taken living animals 
from the bodies of female beasts hours after death. The author has done the 
same in the case of a fox.§§ 

* See cases 65 to 67, author's article in Witthaus and Becker: " Medical Jurispru- 
dence," vol. 11, pp. 370-376. 

t "Med. Leg.," vol. 11, p. 11. + "Diet, des Sciences Med.," xxx, p. 388. 

§ "Monats. f. Geburtsh.," April, 1862. || "Traite des Pertes de Sang." 

** G. A. Reiss: "Gentleman's Magazine," vol. xxix, p. 390. 
ft "Trans. Obstet. Soc. London," xiv, p. 240. %% Ibid., xni, p. 88. 

§§ For instances in which living children have been extracted from fifteen to thirty-two 
minutes after the mother's death, consult Breslaw: "Monats. f. Geburts.," B. 20, p. 62; 
Pringler: " Monats. f. Geburts.," B. 34, S. 244 u. 251; Botherston: "Edinburgh Med. Jour.," 
April, 1868, p. 930; Welponer: "Wiener med. Presse," No. 1, 1897; Buckel: "Trans. Lon- 
don Obstet. Soc," xix, p. 179; Edgar: Witthaus and Becker, "Medical Jurisprudence," vol. 
11, pp. 369-379 (William Wood & Co., New York, 1894). 



730 PATHOLOGICAL LABOR. 



XXIX. THE METRORRHAGIA OF LABOR; PARTUM OR INTRA-PARTUM 

HEMORRHAGE. 

For convenience' sake, I am accustomed to describe intra-partum hemor- 
rhages as those of — (i) the first and second stages; and (2) of the third stage. 
(1) Intra-partum hemorrhage of the first and second stages: This is due principally 
to (a) premature separation of a normally or abnormally situated placenta; (b) 
ruptures of the uterus or cervix; and (c) fibroid tumors, malignant disease of the 
genital tract, or rupture of varicose veins. (2) Intra-partum hemorrhage of the 
third stage; Here, first and foremost stands (a) uterine inertia as the most impor- 
tant etiological factor; uterine inertia occurring with a partial or complete separa- 
tion of the placenta. Next in importance come (b) lacerations of the genital 
tract, namely, of the lower uterine segment, the cervix, vagina, and perineum. 
Another important cause, not often taken into account, is (c) insufficient con- 
traction of the lower uterine segment in cases of low implantation of the placenta. 
Here, while the fundus contracts firmly and completely, an imperfectly contracted 
lower segment permits of fatal hemorrhage from the open blood-vessels of the 
low-situated placental site, (d) Partial or complete inversion, although a most 
infrequent cause, must be enumerated ; and the likelihood of fibroids of the uterus 
or cancer of the genital tract must be borne in mind. 



PART SIX. 



Physiological Puerperiurru The Puerperal 

Woman. 



DEFINITION. INTRODUCTION. 

I. GENERAL PHENOMENA. Exhaustion. Chills. After=pains. Pulse. 
Temperature. Respiration. Skin. Kidneys. Muscles. Blood. Heart. 
Weight. Psychical Changes. 

II. LOCAL PHENOMENA. External Genitals. Vagina. Cervix and Cervical 
Canal. Lochia. Bladder. Involution. (1) Height of Fundus. (2) 
Uterine Muscles. (3) Vessels. (4) Decidua. (5) Placental Site. (6) 
Adnexa. Alterations in Mammae and Milk Secretion. Subsequent Im- 
pregnation. 

III. DIAGNOSIS OF THE PUERPERIUM. 1. Signs of Recent Delivery in 

the Living and the Dead. 2. Primipara and Multipara. 3. Feigned 
Lying=in State. 

IV. MANAGEMENT OF THE PUERPERIUM. 1. Introduction. 2. Asepsis. 

3. Rest. 4. Professional Visits. (1) Temperature. Pulse. Respira- 
tion. (2) Height and Condition of the Uterus. (3) The Lochia. (4) 
External Genitals. (5) Bladder. (6) The Bowels. (7) (8) The Breasts 
and Nipples. 5. Diet. 6. Posture and Duration. 7. Prophylaxis. (1) 
Abdominal Binder. (2) Pelvic Binder. (3) Medication. (4) Massage 
and Exercise. (5) The First Use of the Corset. 8. The Examination 
of the Puerperium. 



Definition. — The puerperium is the period from the completion of the third 
stage of labor to the time when the uterus has returned to its normal dimensions. 
Its duration is six weeks or more. 

Introduction. — The size of the uterus at the fortieth week is 12 inches X 
9 inches X 83- inches; its weight two pounds, and capacity 400 cubic inches. 
The size of the uterus at the end of the puerperium is 3+ inches X 2 A inches 
X ii inches; its weight an ounce and a half to two ounces, and capacity one 
cubic inch. The changes which go on in the uterus and its adnexa during 
this period and that bring about the above results are known as the changes 
of involution. The process is a physiological one, but closely borders on the 
pathological. To understand this we have only to remember (1) the absorption 
of two pounds of uterine tissue; (2) the formation of thrombi in the uterine 
walls; (3) the rapid cell production upon the internal surface of the uterus; 
(4) the atrophy and fatty metamorphosis in the uterine walls; (5) the tearing 
across of blood-vessels at the placental site, leaving large raw surfaces with 
the dangers of septic absorption; and, finally, (6) in most cases, including 
all primiparae, the actual traumatic lesions in the nature of contusions and 
lacerations of the cervix, vagina, and vulva. 



I. GENERAL PHENOMENA. 

Exhaustion. — The action of the recuperative forces of nature is seen to 
great advantage after normal labor. As a rule, the patient recovers from 
the trying ordeal much more rapidly than would be expected, and in the absence 
of excessive hemorrhage or septic infection, this is usually the case even after 
severe and protracted labors and operative delivery. Immediately after 
delivery there is a natural tendency to rest and sleep, and from this repose 
the woman wakes in a state of perspiration and much refreshed and strengthened. 
Nervous, irritable women, however, do not readily fall asleep at this period. 
More or less thirst is present, due to increased excretion by the skin and kidneys, 
with a certain amount of burning pain in the external genitals, depending 
upon birth traumatisms. 

The Post-partum Chill. — A chill of short duration, but which may be pro- 
nounced in character, frequently follows the completion of labor. The pulse 
and temperature are not altered and the chill is not of clinical importance. 
It is most frequently observed after rapid labors, and is probably due to the 
internal congestion caused by the sudden decrease in the intra-abdominal 
pressure which causes a rapid recession of blood from the surface of the body. 
The chill disappears without treatment, but something can be done to aid 
the recovery of the circulatory equilibrium by covering the patient with warm 
blankets. The chill may also be due to the wetting of the surface by perspira- 
tion, blood, and amniotic fluid; to the sudden cessation of muscular effort ; to 
loss of blood, or to withdrawal of the warm fetus and placenta. 

733 



734 



PHYSIOLOGICAL PUERPERIUM. 



After-pains. — Post-partum contractions which continue for several days into 
the puerperium are frequently seen in practice and are quite painful at times. 
They may occur spontaneously or only when the child is applied to the breast. 
They appear more commonly on the first than on the second day and affect 
multiparas by preference. When a primipara has after-pains, they occur, as 
a rule, as a sequel to some particular type of labor, such as involves precipitate 
delivery, or previous overdistention of the uterus, i.e., twins or hydramnios. 
They are also associated at times with the retention of blood-clots and decidual 
structures. While the same factors may be present in the after-pains of mul- 
tiparas, they are often notably absent. 

Pulse. — With the rapid fall in arterial tension which occurs during and 
after delivery there is a marked diminution in the frequency of the pulse. From 
60 to 70 is about the normal rate after delivery, and occasionally it is even 
less. A rapid pulse at this time should lead the attendant to suspect the exist- 
ence of hemorrhage or some other complication. I found the pulse in 141 7 
observations one hour after deliverv as follows : 



40 


to 


50 


in 


2 


cases. 


100 to no 


in 


48 


50 




60 


1 ' 


13 


" 


no 120 


* ' 


2 3 


60 




70 




345 


" 


120 130 




3 


70 




80 


" 


566 


" 


130 140 




2 


80 




90 


" 


302 


" 


140 150 




2 


90 




IOO 




no 
Total 




160 
141 7 cases. 




1 



The pulse of the normal puerperium is slow and soft, and often irregular and 
intermittent. It is also very irritable and easily accelerated by trivial causes. 
But these qualities are by no means constant in all puerperae, at least in notable 
degrees. Temesvary states that a slow pulse occurs in but 60 per cent, of 
normal puerperal women. In certain cases the pulse-rate falls to 36, 32, even 
to 30 beats per minute. The frequency before delivery is about 86, while 
the average frequency throughout the puerperal period is about 63, so that 
the result of delivery is a reduction in the pulse-rate of over 20 beats. Imme- 
diately after delivery the pulse falls to about 72, but after irregular labors 
not below 75. The rate now sinks a little each day until it arrives at a minimum 
(average 57) on the eighth day. It remains at this level until a period near 
the end of the second week, when it begins to rise again until it attains its 
normal level. This tendency to a lowering of the pulse-rate is antagonized 
by hemorrhage or fever from any cause, so that a pulse-rate of moderate 
frequency early in the puerperium may or may not have an unfavorable sig- 
nificance. As the effects of the complications wear away, the slowing of the 
pulse may assert itself later in the puerperal period. When a slow puerperal 
pulse becomes accelerated without evident cause, we should fear possible em- 
bolism of the lungs. The causes of the slow pulse of the puerperal period 
are still unknown. It is likely that several factors co-operate to produce this 
result. One is the absolute rest in bed, another the lowering of the arterial 
tension, a third the relief of the lungs which leads to slowing of the respiration, 
etc. But if these factors alone were the occasion of a slow pulse, the latter 
should be common to all puerperae. The absence of constancy in this respect 
appears to point to the nervous system, which shows such individual peculiarities, 
as largely responsible. Certain unknown factors may produce the slow pulse 
through the vagus nerve or accelerator nerves of the heart. The apex of the 
heart is lowered nearly f inch (2 cm.) after expulsion of the fetus, and a slight 
impurity of the first sound manifested by a blowing murmur persists for 



GENERAL PHENOMENA. 



735 



about a week in about three-fourths of all puerperse. The uterine souffle has 
been found to last, on an average, about fifty-six hours after delivery, and con- 
siderably longer if the puerperium is abnormal. It is less marked than during 
pregnancy and its persistence beyond a certain period shows a delay in the 
process of involution. 

Temperature. — This is slightly raised by the act of labor, so that the measure- 
ments taken just before and just after labor should exhibit a certain difference. 
This physiological increase is not to be confounded with a considerable elevation 
seen in individual cases, which lasts but a short time, and which is attributable 
to constipation, a disordered stomach, or mental influence. The physiological 
rise averages about 0.48 F. (0.2 7 C). For the first six or seven hours after 
delivery the temperature continues elevated, and then sinks slowly, so that 
considerably before the expiration of the first twenty-four hours it has returned 
to the ante-partum point. The temperature curve is the same in primiparae 
and multiparae. It varies slightly with the period of the day at which delivery 
occurs. The normal rise of temperature in the puerperium is attributed 
by Temesvary to the changes in the circulation which follow expulsion of the 
child, there being an increase of pressure in the capillaries of the kidneys, liver, 
lungs, and skin. While the temperature is practically normal after the first 
day, there is a very slight constant daily fluctuation throughout the first few 
days, which is doubtless dependent upon the secretion of milk. In 1420 obser- 
variations of the temperature one hour after labor I obtained the following table : 



Tempe 


rature, 97.0° F. 

93.5° F. 

99-5° F. 

100.5° F. 


to 


98.4 F. 

98.4 F. 
100.4° F. 
101.4° F. 


in 380 cases 

•' 748 " 

255 

29 


1 


ioi.c; F. 


" 


102. 4 F. 


4 ' 


' 


102.5° F. 




i° 3 .4° F- 


4 




Total 






. 1420 cases 



Respiration. — After delivery the rate of respiration is lowered, and may 
be anywhere between 14 and 20. The vital capacity is increased. An equi- 
librium is reached at about the third or fourth day. The type of respiration 
either continues to be thoracic from the habit acquired in pregnancy, or it 
becomes abdominal or mixed. The expired air contains a larger proportion 
of water and carbon dioxid than normal. This fact maybe readily appreciated 
in a hospital ward full of recentlv delivered women if the ventilation is not 
of the best. I found the respirations in n 73 cases one hour after delivery 
as follows: 



Respirations, 15 to 20 in 4S6 cases. 



20 


25 


461 


25 ' 


30 


' 1S6 


3° 


35 


23 


35 ' 


40 


14 


40 


' 45 


2 


55 ' 


' 60 


1 



Skin. — The free perspiration of the first four or five days of the puerperium 
is due undoubtedly to the increase in metabolism which is connected with uterine 
involution and the puerperal loss of weight. This active sweating exposes the 
woman to colds, and she must be carefully protected from overheating, sudden 
cooling, draughts, etc. The functions of the skin become normal at the end 
of the first week. The sweating is accompanied by abundant desquamation, 



736 PHYSIOLOGICAL PUERPERIUM. 

which aids in the disappearance of the pigmentation and oedema of pregnancy. 
The puerperal sweat is rich in butyric acid. 

Stomach and Bowel. — The puerperal woman appears to have little inclination 
for solid food until lactation is established, after which the appetite becomes 
awakened. Digestion is slow throughout the puerperium and indigestion 
is readily provoked. These peculiarities appear to be due to the readjustment 
of the gastro-intestinal tube following the expulsion of the child. Thirst is 
often notably increased at the outset of the puerperium. A spontaneous move- 
ment of the bowels seldom occurs during the earliest puerperal days. The 
bowels have generally been evacuated thoroughly before delivery, and but 
little nutriment is taken until some hours after this event; the intra-abdominal 
pressure is reduced to a minimum and the natural peristalsis is much depressed ; 
the woman is in perfect repose in the recumbent position; the perspiratory 
function is highly augmented, to say nothing of the activity of the kidneys, 
the lochial discharge, and the beginning secretion of milk. Through the 
coincidence of all these factors a natural stool would be almost an impos- 
sibility. 

Kidneys. — During the first few hours after delivery there is usually little 
desire for urination, owing to a paretic state of the muscles of the bladder, the 
result of the strong compression during the expulsion of the child. The early 
urine is concentrated. An important fact in the physiology of the puerperium 
is the length of time which the patient can retain her urine without any sensa- 
tion of repletion. In the statistics of Temesvary 35 per cent, of the women 
went from twelve to twenty -four hours without a spontaneous passage of 
urine, and in 6 per cent, this interval was prolonged to a period between twenty- 
four and thirty-six hours. The amount of urine which collects in the bladder 
during these protracted intervals is considerable. Catheterization under these 
circumstances is not desirable, and should be replaced by gentle frictions over 
the bladder, warm wet compresses or poultices, or simple elevation of the 
upper part of the trunk. (See Treatment.) The quantity of urine passed daily 
during the first puerperal week is larger than that voided by the non-pregnant 
woman, but considerably less than the amount secreted during the last weeks 
of pregnancy. In the first day or two of the puerperium the amount of urine 
is increased over that of subsequent days, and the density should be below 
1020; after the third day it is usually above 1020. An increase in the 
amount of urea excreted during the lying-in period is attributed to the 
process of involution. Albumin occurs in the urine of many puerperal women, 
not reckoning cases of albuminuria of pregnancy. This is the result of the 
renal stasis which results from the act of labor. After the first twenty- 
four hours albumin should disappear from the urine. If the woman had 
albuminuria before pregnancy, the urine does not clear up until toward 
the close of the first week. Sugar (lactose) is found in the urine whenever 
there is any impediment to the secretion of milk, as in cases in which the child 
does not nurse sufficiently. But this stops abruptly if the woman does not 
nurse her child at the outset. The percentage of sugar is greatest at about 
the fourth or fifth puerperal day. Peptonuria attributed to the involution 
of the pregnant uterus begins in the second half of the first puerperal day, 
and, as a rule, lasts four or five days. This phenomenon is not constant. 

Muscles. — The muscular fatigue and the semi-paretic state of certain muscles 
which result from the act of labor disappear promptly, as a rule; but exception- 
ally they last for days or even weeks. The woman has a somewhat similar 
experience when she first gets up, but this also rapidly disappears. Delicate 



LOCAL PHENOMENA. 737 

women often exhibit an unnatural degree of mobility of the pelvic articu- 
lations. 

The Blood. — It was formerly supposed that the watery elements of the 
blood were increased during pregnancy, while the hemoglobin and red cor- 
puscles were relatively diminished. Later investigations have tended to dis- 
prove this statement. The decrease in hemoglobin and red corpuscles observed 
after delivery is probably due to hemorrhage, which occurs even in normal 
cases. The hyperinosis of pregnancy is increased during the puerperium owing 
to the presence of effete material in the circulation. The number of leucocytes 
in the blood is at a maximum during the third stage of labor. It sinks rapidly 
after delivery and attains a minimum at about the twelfth hour of the puerperal 
period. It begins to increase on the second day or a little later, to undergo 
another reduction when the secretion of milk has become established. The 
number of red blood-corpuscles and the proportion of hemoglobin also undergo 
a diminution after delivery, dependent in degree upon the amount of blood 
lost during labor. This reduction is followed by an increase, so that by the 
end of the first puerperal week the blood is of the same quality as before de- 
livery. 

The Heart. — In normal cases the heart speedily adapts itself to the decreased 
arterial tension and diminished volume of blood. It has been asserted that 
in consequence of the extra work required during pregnancy a hypertrophy 
of the left ventricle takes place which disappears after delivery, but this is 
not proved. (Compare Physiological Pregnancy, Part II.) 

Weight. — During the first week there is loss of weight consequent upon 
the diminished appetite, the increased excretions by the skin, and the normal 
retrograde changes in the intra-pelvic viscera attendant upon the process 
of involution. The loss is estimated at nine or ten pounds. In addition to the 
loss of weight through the act of labor itself, there is a further loss which results 
from the great activity of the various secretions, the lochial discharge, involution 
of the uterus, absorption of oedema, etc. But with a proper amount of nourish- 
ment the reduction is not excessive. Equilibrium in weight is reached in 
about six or eight weeks, when it corresponds to the average before conception. 
In primiparae, after twin pregnancies, and in women who do not nurse their 
children the loss in weight is proportionately greater. Delicate women may not 
regain their normal weight for months. 

Nervous System. — During the first few days of the puerperium the woman 
is in a condition of irritable weakness which involves the special senses and 
the mind. This condition is aggravated by after-pains and by attempts of 
the child to nurse, etc. Mental excitement sometimes leads to rise of tem- 
perature (see Fever, Part VI), sleeplessness, and other ill effects. It is self- 
evident that every source of annoyance should be avoided. 



II. LOCAL PHENOMENA. 

External Genitals. — After delivery the external genitals are bruised and 
swollen and, especially in primiparae, are the seat of various abrasions and lacera- 
tions. There is gaping of the labia majora and minora, and if labor has been 
prolonged considerable oedema may be present (Fig. 478). The vulva and 
perineum lose their secretions through absorption of the infiltration; the vari- 
cosities in the veins diminish, and pigmented areas fade out. The various super- 
47 



738 



PHYSIOLOGICAL PUERPERIUM. 



ficial and deep contusions and lacerations gradually disappear, healing by epithe- 
lial migration, leaving whitish scars. In primiparae, in addition, the remains of 
the hymen undergo necrosis with the persistence of the so-called caruncular for- 
mations (Fig. 28). The abdomen remains wrinkled and pendulous for weeks and 
never regains its original appearance. Striae atrophicae are often apparent, 
dating from pregnancy. 

Vagina. — The vagina is at first relaxed, its mucous membrane is smooth and 
flabby and the rugae are absent. In a few weeks it very nearly regains its normal 
condition. It becomes narrower and shorter, although it never returns to its 
original dimensions. The folds which were effaced by the act of labor form 
anew, but never acquire their original number or sharpness of contour. The 
ostium vaginas tends to remain somewhat patulous, especially behind, and a 
certain prolapse of the vaginal walls within the ostium is often present. The 
process of involution goes on more rapidly near the ostium vaginae than in the 
upper portion. 

Cervix and Cervical Canal. — The cervix after delivery is much distorted, but 




Fig. 924. — Lochia on the 
Second Day of the 
Puerperium. 1, a, Epi- 
thelium; 3,4, white blood- 
corpuscles; 5, red blood- 
corpuscles; 6, decidual 
cell.— (Winckel.) 



Fig. 925. — Lochia on the 
Fourth Day of the 
Puerperium. i, Decid- 
ual cell; 2, white blood- 
corpuscles; 3, red blood- 
corpuscles; 4, epithelium; 
5, micro-organisms. — 
(Winckel.) 



Fig. 926. — Lochia on the 
Seventh Day of the 
Puerperium; Afebrile 
Case, i, Red blood-cor- 
puscles; 2, diplococci and 
monococci; 3, white blood- 
corpuscles; 4, epithelium; 
5, decidual cells. — (Win- 
ckel.) 



the external os can always be recognized (Figs. 538 and 644). Lacerations at this 
point are usually present. The cervix and vagina cannot at first be clearly 
distinguished from each other, but after twelve hours the distinction becomes 
marked. At the tenth day post partum the internal os admits the passage 
of the index-finger readily in about 60 per cent, of primiparae and about 70 per 
cent, of multiparas,* but soon thereafter closes. The external os admits the 
finger much longer and never exactly regains its former condition. Immediately 
after delivery the cervix gapes, and the canal is so patulous that it will accom- 
modate half the hand. This condition rapidly changes through thickening of 
the cervical wall, the cervical folds reappear at the same time, and by the 
twelfth day its involution is almost complete. On the contrary, the portio 
vaginalis requires some five or six weeks to regain its original condition. The 
hps of the external os immediately after delivery project into the vagina as soft 
tumors. If the anterior lip has been incarcerated during labor, it may reach 
as far as the vulva. 

The Lochia.— By this term is understood the utero-vaginal discharge which 
* Author's observation of several hundred cases. 



LOCAL PHENOMENA. 



739 



^QorFiRaTj^ 



7*- Da^ 



continues for two or more weeks after delivery. For the first three or four days 
it is called the lochia rubra (red lochia), and consists principally of blood and 
blood-clots with some admixture of the epithelial elements of the vagina and 
cervix and fragments of decidua (Fig. 924). For the next three or four days it 
is mainly serous in character and is called the lochia serosa (serous lochia) 
(Fig. 925). After this, as the separation, disintegration, and casting-off of the 
products of involution go on, it becomes thicker and whiter in color and is 
called the lochia alba (white lochia) (Fig. 926). It contains disintegrated tis- 
sues of the birth canal, the secretions from granulating wounds, and micro- 
organisms, which, it should be 
noticed, are not found for the first \ .... ... %£j. 

day or two, are confined to the 
Vaginal secretions, and under ordi- 
nary circumstances do no harm. 
In normal conditions the uterine 
lochia is to be regarded as sterile. 
The amount of the discharge has 
been estimated as follows : For the 
first four days 2I pounds (1 kilo) ; 
for the second two days, about 9 
ounces (256 gm.); until the ninth 
day, nearly 7 ounces (199 gm.). 
Under ordinary circumstances if 
more than one change of napkins 
is needed every four hours for the 
first few days, the amount is to be 
regarded as excessive. After the 
first two or three days the lochia 
has a peculiar sickish, but not 
putrid, odor. It is important that 
the physician should be familiar 
with this odor in order that he 
may recognize a departure from 
the normal and that odorless vulval 
dressings be employed. The dis- 
charge is more profuse in multiparas 
than in primiparae and in women 
who do not nurse their children 
than in those who do. A diminu- 
tion in the usual amount of the 
discharge should be regarded with 
suspicion. Suppression is often a 
sign of sepsis. 

The Bladder. — Owing to the 
increased quantity of urine, the sudden decrease of intra-abdominal pressure, 
reflex urethral spasm, the bruising and swelling of the tissues, and especially 
to the recumbent position, retention of urine frequently occurs. 

Involution. — After the expulsion of the fetus and secundines the uterus 
contracts upon itself, so that the fundus is below the level of the umbilicus. 
Immediately after delivery examination reveals a mass equal to that of a preg- 
nant uterus at the twentieth week. Its weight is 26 to 35 ounces (750 to 1000 
gm.); length 6.3 to 7 inches (16 to 18 cm.); length of cavity 5.9 inches (15 cm.); 







Fig. 927. — Height of the Fundus during 
the First Ten Days of the Puerperium. 
— (From the author's measurements.) 



740 



PHYSIOLOGICAL PUERPERIUM. 



thickness of wall 0.98 to 1.57 inches (25 to 40 mm.). At the eighth day of the 
puerperium the mass of the uterus should be reduced one-half. Thus, the 
weight after delivery is 26 to 35 ounces (750 to 1000 gm.); at eighth day, 14.9 to 
17.6 ounces (400 to 500 gm.) ; on the fourteenth day, 13 ounces (350 gm.) ; on the 
fourth week, 7.5 ounces (200 gm.). Finally, at the end of two months the uterus 

has regained its original 
weight of 1.85 to 2.78 
ounces (50 to 75 gm.) and 
length of 2.95 inches (7 cm.). 
I found the length of the 
uterine cavity from the ex- 
ternal os, measured with a 
sound on the tenth day of 
the puerperium in 1 1 9 primi- 
parae, 3.21 inches (8.15 cm.), 
and in 99 multiparas 3.53 
inches (8.97 cm.).* The 
first step in involution is 
the permanent contraction 
of the uterus, which should 
occur about one and a half 
or two hours after the birth 
of the child and immedi- 
ately after the expulsion of 
the placenta. Active contractions are succeeded by a period of retractility 
due to the natural resiliency of the uterine wall and muscular tonus. This is 
also exerted during the period of active contraction in such a manner that 
each active post-partum contraction effects an absolute and permanent 
reduction in the size of the uterus. It is due to the persistence of this retrac- 




Fig. 928. — Puerperal Uterus Fifty-three Hours 
Post Partum. Normal Puerperium. — (Modified 
from Sellheim.) 



Thnmous. - 
in UtCavi™ 
Transverse 
andOblioue muscle Bundles 
Boundary 
(f loose attachment of Peritoneum 
l/temves, pouch 
£oundary if loose altathTnerarf 
Peritoneum •" 
Post Vag fornix 
Douglas pouch 
Rectum 

Rectum 




Bladder 

AntMag. fornix. 
■ Prepuce of Clitoris 
. aitoris 



-' Urethra 

Labium minus 

Vagina 
s Vag portion of Cervix 

Perineum 
""" , Ext. SphincterAni. 

Int. SphincterAni 
__ Rugous mucous Mem. of Rectu 
Anus 



Ext. SphincterAni, 



Fig. 929. — Sagittal Section of a Puerperal Uterus Fifty-three Hours Post Partum. 

Normal Puerperium. — (Sellheim.) 



tility that involution becomes possible. Uterine retractility is under the 
influence of the central nervous system, as shown by its inhibition under the 
influence of mental emotion even late in the puerperium. Its arrest under these 
conditions may be accompanied by secondary hemorrhage. The amountjand 

* If the practitioner wishes to estimate the progress of involution with thejsound, the 
bladder should first be completely emptied. 



LOCAL PHENOMENA. 



741 



character of nutriment and the rate of metabolism are also known to modify 
the process of involution, which goes on more slowly by night than by 
day. The uterus in which involution is already under way may still undergo 
active contractions (after-pains) from reflex stimulation by the nursing child. 
The uterus is known to be slightly smaller just after delivery than at the com- 
pletion of the first three puerperal days. This is due to the manipulation of the 
uterus in connection with the third stage of labor and the early post-partum 
hours, producing an initial reduction in size which is followed by a slight reac- 
tion. Measurements of the height of the fundus above the symphysis during 
the early puerperal days are as follows. 

(i) Height of Fundus. — From careful measurements taken in 321 primi- 
parae and 709 multiparas, during non-febrile puerperia, I found the height of the 
fundus above the symphysis to be as follows : 

TABLE OF HEIGHT OF FUNDUS ABOVE SYMPHYSIS.* 



Time. 



321 Primipar^e. 
Average Height. 



after 



Immediately 

third stage 5.93 

First day 1 6.06 

Second day 4.61 

Third day j 4.49 



Fourth day. 
Fifth day . . . 
Sixth day . . . 
Seventh day. 
Eighth day. , 
Ninth day. . . 
Tenth day . . . 



3 .»2 

3- J 4 
3- J 3 
2.91 
2.50 

2-54 
2.49 



m. 
in. 
in. 
in. 
in. 
in. 
in. 
in. 
in. 



15.24 

11.50 

11.40 

9.60 

7.90 

7-85 
7.40 

6-35 
6.40 

6-34 



cm.) 
cm.), 
cm.). 

cm.), 
cm.), 
cm.), 
cm.), 
cm.), 
cm.), 
cm.) 
cm.), 



709 Multipara, 
Average Height. 



Total Average. 



5-92 

5-35 
4.66 
4.26 
3.68 

3- 2 7 
2.97 
2.89 
2.60 
2.10 
1.96 



m. 
in. 
in. 
in. 
in. 
in. 
in. 
in . 
in. 
in. 
in. 



(15.10 
(13-60 
(11.50 
(10.79 
( 9.20 
( 8.30 

( 7-5° 
( 7.40 

( 6.45 
( 5-3° 
( 5-°° 



cm.) 
cm.) 
cm.). 
cm.), 
cm.), 
cm.) 
cm.) 
cm.), 
cm.), 
cm.), 
cm.), 



5-92 
5-7° 
4-63 
437 
3-75 
3.20 

3-42 
2.90 

2-55 
2.32 
2.22 



in. ( 
in. ( 
in. ( 
in. 

111 . 
in. 
in. 
111 . 
111. 
in. 
in. 



15-8 

12.90 

11.30 

11. 10 

9-52 

8.00 

8.48 

7.40 

6.40 

6.00 

s.6o 



cm.) 
cm.), 

cm.), 
cm.) . 
cm.), 
cm.), 
cm.). 
cm.), 
cm.), 
cm.), 
cm.). 



Statistics of the width of the uterus show a corresponding diminution. During 
the first two puerperal days the width is greater than immediately after de- 
livery. Upon the tenth day post partum the uterus does not lie entirely in 
the true pelvis, as is so often stated. My observations show that in primiparae 
the fundus on the tenth day is still 2.49 inches (6.34 cm.) above the symphysis, 
and in multiparae 1.96 inches (5.00 cm.) — a total average of 2.22 inches (5.60 
cm.). While its position at the onset of the puerperium .is one of retrodis- 
placement (Fig. 929) as a result of its w T eight and the laxity of its ligaments, the 
conditions are reversed in involution, so that by the ninth day the position 
is one of anteversion or anteflexion, which increases as involution progresses 
(Fig. 928). A certain degree of rotation on the longitudinal axis is often pres- 
ent. Hansen (cited by Temesvary) has made measurements which show that 
the distance from the fundus to the external os diminishes up to the tenth 
week post partum. These figures appear to be a suitable criterion for the 
duration of the process of involution. They also show that the uterus never 

* Temesvary gives the following table : 

Immediately after delivery 4.29 inches (10.91 cm.). 



First day 5.33 

Second day 4.9 

Third day 4-39 

Fourth day ' 4.02 

Fifth day 3.66 

Sixth day 3.24 

Seventh dav 3.00 

Eighth day' 2.88 



(13.55 cm.) 
(12.45 cm.), 
(11. 16 cm.), 
(10.21 cm.). 
( 9.29 cm.), 
( 8.22 cm.), 
( 7.61 cm.), 
( 7.32 cm.). 



742 



PHYSIOLOGICAL PUERPERIUM. 



entirely regains its original length. By this means it may also be shown that 
involution occurs with less delay in multiparas and nursing mothers. Involution 
is also known to be delayed after hydramnios, twin births, labor in contracted 
pelves, hemorrhage, premature delivery, puerperal disease, and the action of 
psychical influences. 

(2) Muscle. — We know that the original muscular fibers of the uterus 
increase in size during gestation. Therefore in involution the hypertrophied 
individual elements must undergo reduction to their normal dimensions. 
This is effected by fatty metamorphosis of the protoplasm of the muscle- 
fibers. The primitive fat-drops coalesce to form large collections between 

the muscular bundles, whence the fat is taken up by 
the blood- and lymph-capillaries. The appearance of 
fat-drops in the uterine muscle-cells is an evidence on 
the first day post partum. The process of involution 
affects the nuclei of the muscle-cells as well as the sub- 
stance proper. Within recent years it has been shown 
that a glycogenesis occurs at the same time as fatty 
transformation (Fig. 930). 

(3) Vessels. — Involution of the larger vessels is 
accomplished by proliferation of the intima occurring 
side by side with fatty degeneration of the media. The 
capillaries appear to be destroyed outright by compres- 
sion, passing rapidly into a state of fatty degeneration. 
The nutrition of the uterus is maintained by the par- 
tially obliterated vascular trunks. 

(4) Decidua. — When the membranes are cast off 
at the completion of delivery, the separation occurs at 
the so-called ampullary ~ layer of the decidua. This 
leaves a thin stratum of decidual tissue which serves as 
a temporary lining for the uterus (Fig. 931). At the 
serotinal portion the surface is more or less bloody. 
The remainder of the lining is raw, shreddy, and uneven 
through the forcible separation of the dilated uterine 
glands. Portions of the decidual layers which are nor- 
mally cast off at birth may remain to undergo gradual 
necrosis and expulsion with the lochia (Figs. 924 to 
926). The persistent portion of the decidual tissues 
undergoes transformation into connective-tissue corpus- 
cles, thereby laying bare the original mucous mem- 
brane of the uterus, from the epithelial cells of which 
a new mucosa is generated. The epithelium in this 

case comes from the uterine glands and rapidly proceeds to cover the bare 
septa between the latter. This process of repair is always accompanied by 
an abundant exudation and leucocytosis. According to some authorities, the 
persistent decidual cells become transformed into epithelium. 

(5) Placental Site. — This portion of the inner surface of the uterus neces- 
sarily undergoes a reduction in size corresponding to that of the uterus itself. 
The open sinuses are at first protected by firmly adherent clotted blood and 
the majority become occluded by thrombosis, the remainder by muscular 
compression. The placental site is still recognizable for from four to six weeks 
after deliver}- and is indicated by a prominence f to £ inches in width (1 to 
2 cm.), the former blood-vessels persisting only as pigmented points. It thus 




Fig. 930. — Muscle : fi- 
bers of the uterus 
on the Sixth, Tenth, 
and Eighteenth 
Days of the Puer- 

PERIUM. 



LOCAL PHEXOMEXA, 



74 



appears that the placental site is the last portion of the uterus to undergo 
complete involution. 

(6) Adxexa. — The ovaries, enlarged d 
their original dimensions; the dilated an< 
and tortuous; the peritoneal coat of the 
of the broad ligament become unfolded anc 



e pregnancy gra dually resume 
retched tabes become narrow 
rus contracts, and the laminae 

:e mere arc read; each ::her. 



..#*«. 



****** 






a4 



• r» 



V-*-. 



> 



>%'■ 



.-.: 
-£ 



■ f 



- 



Changes in the Breast and Milk Secretion. — The changes in the breast up 
to the time of the puerperium have already been described. During the first 
three days of this period the so-called colostrum, an immature milk, is secreted 
This is a turbid, watery fluid 
which exhibits whitish or yel- 

:sh streaks. The micro- 
scope shows that colostrum is 
an irre^.har enculsicn. its cat- 
erers zei::g c: ur.e:ual size 
and adhering to one another 
(Fig. 934). This point serves 
to distinguish between this 
fluid and milk, the latter being 
a perfect emulsion (r 
Agglomeration of the fluid fat- 
crotcs into c ::::c a:: masses 
constitutes the so-called colos- 
trum corpuscles. It is prob- 
able, however, that the latter 
really represent a complete 
fatty degeneration of the 
epithelium of the mammary 
gland. Colostrum is poor in 
casein and rich in serum-albu- 
min; therefore, unlike milk, 
coagulates on boiling. The 
secretion of the breast loses 
its coagulability at the latest 
by the fourth day, showing the 
period of transition from colos- 
trum to milk. The amount 
of breast secretion during the 
colostrum period is relatively 




Fig. c:: — Rec-exzra:::-::- Mv::y = Mz::ira:;z :? 
the Uterus ox the Sixth Day of the Puer- 
perium. :. Portion of necrosed decidua with leu- 
cocytes free and embedded; 2, edge of firm decidua ; 
3, beginning formation of new epithelium; 4, glands 
line a —it a. eaitheli-ant : ~ all :: rranulaticn tissue 
under the neerzsed decidua : eland - capillary 



insignificant. After its tran- 



':'.: : d-vessel 
aetiaual ce"d 
: nvascle :: 
decidua : :n" 



rating ana ae. 

rk :: :;nneet: 
: = . deeae;: t :r 

e-sltaa. ed cells. - 



sition into milk the amount 
rapidly increases. From the 

third puerperal day the breasts increase rapidly in size and usually exhibit 
fulness and tension. Individual lobuli may often be felt, giving the gland a 
nodular character (Fig. 935). The swelling about the gland proper may even 
extend to the axilla, and may be accompanied by more or less pain. That 
a milk stagnation or milk fever ever occurs as a physiological phenomenon 
is now disputed; all evidence of this sort will doubtless, in time, come to be 
regarded as due to bacterial infection. (See Fever, Part X.) The period of 
active congestion which ushers in the secretion of milk proper does not last 
over two days when the woman nurses her child, and somewhat longer when 
she does not. In the latter case when there is no demand for its secret!: a 



744 



PHYSIOLOGICAL PUERPERIUM. 



of milk, the latter gradually assumes the character of the original colostrum, 
and finally disappears altogether. The emptying of the breast in lactation is 
brought about as follows : The infant first causes an erection of the nipple so 
that the first milk that enters the sinuses of the excretory duct is abstracted 
by the pressure and suction of its lips. The vis a tergo is then brought into 
play through reflex stimulation of the gland by the act of suction, so that an 
increase occurs in the secretory pressure. In a few moments after the appli- 
cation of the child a pain is felt in the 
breast and the milk is then seen to jet 
forth. This may often be observed simul- 
taneously in the opposite breast, and even 
in both glands, quite independently of the 
act of suction, from the mere thought of 
suction. 

Human milk proper is a white, opaque 
fluid with an alkaline reaction, sweetish 
taste, and density of 1030. The micro- 
scope shows it to be composed of an 
emulsion of fat-drops in a fluid known as 
the milk plasma (Fig. 933). These fat- 
drops rise after the milk has stood for a 
few hours and compose the cream. During 
the first eight days of the puerperium, or 
up to the fourth or fifth day of actual 
secretion of milk, extraneous formed ele- 
ments may be recognized by the micro- 
scope — blood-corpuscles, fibrin, colostrum 
corpuscles, etc. The fat-drops of the milk 
are composed of a number of fatty acids 
(palmitic, stearic, oleic, myronic, butyric, 
etc.) in combination with the glycerin 
radical, thereby forming triglycerides or 
neutral fats of the same class as those 
which make up adipose tissue of animals 
in general. The most important soluble 
ingredient of milk is the proteid matter, 
which appears to undergo considerable fluc- 
tuation in quality, so that a given test does 
not always respond in the same fashion. 
It is admitted that the principal proteid 
constituent is casein, and some chemists 
regard it as the sole proteid of the milk. 
The majority, however, regard serum-albu- 
min and nuclein as normal proteid ingre- 
dients. The existence of an albuminoid envelope about the fat-drops, so long 
maintained undisputed, is to-day denied. Heidenhain claims that the mere col- 
loidal action of the casein in solution suffices to prevent the coalescence of the 
fat-drops. The casein is combined in the milk with calcium phosphate, which 
holds it in solution. If this salt is withdrawn from the combination by the 
addition of a few drops of a weak solution of hydrochloric or acetic acid, the 
casein is immediately precipitated. Spontaneous coagulation is due to the action 
of the Bacillus acidi lactici, which forms lactic acid from the lactose of the milk 




Fig. 932. — Section through ax Inac- 
tive Breast at the Third Week 
of the Puerperium. i, Skin; 2, 
adipose tissue; 3, tubercles of Mont- 
gomery; 4, nipple; 5, milk duct; 6, 
muscle; 7, glandular tissue; 8, milk 
ducts; 9, muscle. — (Bumm.) 



LOCAL PHENOMENA, 



'45 



and thereby precipitates the casein. This separates the milk into a solid and 
a fluid portion known respectively as the curd and whey. Milk which curdles 
spontaneously is made sour through the formation of lactic acid. The action 
of rennet or lab ferment coagulates the milk without souring it. In human 
milk casein is always precipitated in small flocculi. In addition to the 
proteid matter, milk contains milk-sugar (lactose), salts, and traces of a 
diastatic ferment. The amount of secretion of milk is capable of increase up 
to the eighth month, after which it gradually declines. The daily average 
for the first week is about a pint (500 c.c), which gradually increases till at 
its maximum it is over a quart (1.1 liters). As a general rule, lactation is com- 
pleted at the end of a year, but this period is subject to many variations. A 
secretion of milk out of all proportion to the demands of the child is known 
as 1 'polygalactia, and if it persists when the child is not nursing it is termed 
galactorrhea (see Part VII). Defective secretion of milk is common in the 
very young or the elderly, in the delicate, weak, and cachectic. The obese also 
suffer in this respect, the breasts in such women being subdeveloped. According 




Fig. 933. — Contents of Milk, i, Fat- 
globules (milk corpuscles) ; 2 , milk cor- 
puscles with the remains of the proto- 
plasm of the gland epithelium; 3, milk 
corpuscles covered r with nucleated pro- 
toplasm. — (Bumm.) 



Fig. 934. — Contents of Colostrum, i, 
Fat-globules of different sizes; 2, epi- 
thelium of the milk ducts ; 3 , colostrum 
corpuscles. (Leucocytes containing fat- 
corpuscles.) — (Bumm.) 



to Baumm and Illner, there are no true galactogogues, nor can the secretion 
of milk be modified by the diet; but the amount of milk can be much lessened 
by insufficient diet and then brought to the normal by generous regimen. C- The 
composition of milk varies more or less in the same woman, and while the 
gross amount is not affected by diet, the milk may be made richer in fat by 
generous living. The limits of variability appear to be as follows: Proteids, 
1. 41 to 3.50 (per cent.); fat, 1.42 to 5.25; sugar, 5.04 to 7.76; ash, 0.16 to 
0.36. The milk of a primipara is somewhat richer in solids than is that of a 
multipara. Age alone, within certain limits, is without effect upon the com- 
position of the milk. The period of lactation exerts very little influence, al- 
though during the first ten days of the puerperium there is a steady decline 
in the proteid, which thereafter remains constant. Baumm and Illner have 
made many studies in connection with feeding nursing mothers. The milk 
as a whole, when in normal quantity, cannot be increased by feeding, although 
individual constituents may be thus affected. Thus, forced feeding with 
proteids or fats increases the percentage of fatty matter. Carbohydrates 



746 



PHYSIOLOGICAL PUERPERIUM. 



have no effect whatever. Increased ingestion of fluids is practically without 
effect. Illness of the nursing woman does no more than diminish slightly 
the solid constituents. Neither menstruation nor mental emotion has any 
notable effect on the milk. To sum up, we can maintain only one prominent 
truth in this connection: viz., that the richness of the milk— or, in other words, 
the proportion of fat— can be modified in various ways. The following are 
some of the medicaments which, administered to the mother, may enter the 
milk: Certain coloring-matters, ethereal oils (wormwood, garlic, etc.), salicylic 
acid, potassium iodide, the heavy metals (lead, mercury, iron, bismuth), arsenic, 
antimony, atropin, chloral. Narcotics, including alcohol, while having a 
tendency to enter the milk, do so in such small quantities that the infant is 







> 7 



Fig. 935. — Section through an Inactive Breast during the Puerperium. The epi- 
thelium of the acini shows various conditions. 1, Quiescent acinus; 2, acinus dis- 
tended with milk; 3, 4, 5, secreting acini; 6, interacinous connective tissue; 7, capil- 
laries; 8, secreting gland epithelium with large fat-corpuscles in the protoplasm, the 
nuclei being pressed against the cell-wall; 9, formed milk. — (Bumm.) 



not menaced. Human milk is practically sterile when secreted, but can readily 
be contaminated with staphylococci from the milk-ducts and nipple. In 
estimating the amount of milk, the usual methods of palpating the breasts 
and noting the force with which the milk spurts from the nipple are more or 
less sources of fallacy. A more sensible way of arriving at this knowledge 
is by the examination of the infant. By means of a proper scale the child 
may be weighed before and after each feeding. It should nurse from 1.8 to 
7.2 ounces (50 to 200 gm.) according to age every two hours. Direct analysis 
of the milk is required only for the determination of the percentage of fat. 
High specific gravity means low percentage of fat, and vice versa. The micro- 



DIAGNOSIS OF THE PUERPERIUM. 747 

scope also gives information of some value in this direction, as does allowing 
the milk to stand twenty-four hours and computing the thickness of the super- 
natant cream, which should be 10 per cent, of the whole. For quantitative 
work the lactobutyrometer will give approximate results to the practitioner. 

Subsequent Impregnation. — How soon after delivery can a woman again 
be impregnated? G. L. Bonnar * reached some interesting conclusions in 
regard to this question. Not being satisfied with the then generally accepted 
opinion that a month must elapse between the termination of labor and 
a fresh conception, he undertook an investigation into what was known as 
"Hodge's Peerage and Baronetage." His results were as follows: In at least 
nineteen cases the interval between one birth and another was less than 309 
days. In ten cases the interval varied from 309 to 300 days, in two from 
299 to 290, in four from 289 to 280, in one it was 273, in another 252, in 
another 182, in another 173, and in one 127 days. Taking these cases into 
consideration, as well as the post-partum conditions of the uterus, lochia, 
and vagina, Dr. Bonnar placed the earliest date after confinement when the 
woman could again become pregnant as the fourteenth day. Leopold's ob- 
servations appear to prove that the repair of the uterine mucous membrane 
after confinement is not complete earlier than the end of the fourth week; 
that the red and yellow lochia cease at the beginning of the second week, and 
that the white lochia continues until the sixth week. Observations would 
tend to indicate that one-half of those women who do not nurse their children, 
and also those women who menstruate during the period of lactation, have 
their first post-partum menstrual period, and hence ovulation and capability 
of impregnation, within six weeks after confinement. 



III. DIAGNOSIS OF THE PUERPERIUM. 

1. Signs of Recent Delivery. — As the physician is required to render a decision 
not only in the case of the living, but also, in the dead, he must, from signs 
present, state whether or not a recent expulsion of the contents of a pregnant 
uterus has taken place. In the first instance, the case of the living, the decision 
is reached by the usual methods of diagnosis; in the case of the dead, the value 
of an inspection of the uterus and its appendages is added. 

(1) Signs in the Living. — As in the diagnosis of pregnancy, so in the deter- 
mination of the existence of a recent delivery in the living, there are a large 
number of signs of greater or less value. Doubtful signs: The uncertain symp- 
toms prove nothing; they can exist in conditions other than that of the puer- 
perium, and in the male as well as in the female. Probable signs: These include 
signs existing in the genital tract and in the mammary glands. (See Local 
Phenomena of Puerperium.) Positive signs. Positive proof of the occurrence 
of birth is furnished only by the discovery of parts of the ovum. If, upon careful 
microscopic investigation of the lochial discharges (see Figs. 924, 925, and 926) 
we fail to find any evidence of remains of the ovum, we can with the finger or 
curette remove the remains of the placenta from the inner surface of the uterus, 
and demonstrate under the microscope the tissue found, thus fully establishing 
the diagnosis. The demonstration of the shreds of decidua with large nucleated 
and fatty cells is of itself a sure proof. The diagnosis of the puerperal condition 
will rarely be found difficult within ten or fourteen days after parturition. In 
* " Critical Inquiry Regarding Superfcetation, with Cases." 



748 PHYSIOLOGICAL PUERPERIUM. 

multiparae the diagnosis cannot in some instances be positively established after 
the lapse of even a week or ten days. If the case is one of a primipara, the 
character, intensity, and persistence of the signs present will permit a diagnosis 
to be made at a later date. 

Date of Delivery. — We are enabled to answer this question by carefully 
observing the character of the secretion from the breasts; the appearance and 
composition of the lochial discharge; the height of the fundus uteri in the ab- 
dominal or pelvic cavity; and particularly the freshness of the wounds that may 
exist in the genital tract. 

(2) Signs in the Dead. — The diagnosis of recent delivery in the dead rarely 
presents any difficulty. Many, if not all, of the signs of recent delivery occurring 
in the living may be found in the dead, and. in addition, we are able to see 
the alterations in the uterine body and its appendages. The rate of return of 
the uterus to its normal size depends upon so many factors — as the period of 
gestation at which labor occurs, pathological conditions in the pelvis prior or 
subsequent to labor, the general condition of the woman, etc. — that any 
attempt to state positively from a post-mortem examination the exact 
date upon which parturition took place must result in failure. Four to six 
weeks after labor the placental site may still be recognized, but it is smooth 
and barely two-thirds of an inch across, and the places formerly occupied by 
the vessels are now marked by yellow and black spots of pigmentation. As to 
the signs of pregnancy revealed by a post-mortem examination, those of an objec- 
tive character will in most cases be present. There are two which have not yet 
been mentioned: namely, (1) The finding of the ovum, embryo, or fetus within 
its envelopes in the uterus. The gross appearance of the ovum, embryo, and fetus 
in the several months of gestation will be found described on pages 82 and 83, and, 
of course, this furnishes reliable evidence. (2) The presence in one or both ovaries 
of a true corpus luteum. After the Graafian follicle or ovisac ruptures and dis- 
charges the ovum, a certain change takes place in the ruptured follicle which 
results in the formation of the corpus luteum (page 19). Modern investigation 
would seem to sustain the statement that no positive evidence is to be derived 
from either the false or the true corpora lutea. Instances are on record in which 
the so-called true corpus luteum has existed in the absence of pregnancv. 

2. Primipara and Multipara. — In primipara? we find the fragments of the 
freshly torn hymen, fourchette, and possibly perineum. The external genitals 
are usually, also, more swollen, reddened, and sensitive to the touch than in 
multiparas. 

3. Feigned Lying-in State.— (See Feigned Delivery, page 499.) 



IV. THE MANAGEMENT OF THE PUERPERIUM. MOTHER. 

Introduction. — The borderland between the physiological and pathological 
puerperium is not sharply defined. The parturient suffers from slight trauma- 
tisms almost through the entire genital tract; she has thrombi in the uterus at 
the former site of the placenta, and the birth canal is hypertrophied above and 
unduly relaxed below. Such may readily pass into pathological conditions, 
and the obstetrician should supervise all these physiological conditions till the 
transition to disease is no longer likely to occur (see page 733). As already 
stated (Part IV), the physician should remain with the patient for at least an 
hour after the completion of the third stage of labor. During this period, which is 



THE MANAGEMENT OF THE PUERPERIUM. MOTHER. 749 

called "the physician's hour," the abdominal binder and first vulval dressing are 
applied as already described (page 532), after a thorough cleansing of the 
external genitals and neighboring parts with an antiseptic solution. The 
draw-sheet has, of course, been removed and all soiled clothing and bed- 
ding have been replaced by clean material. It is essential, however, that during 
this process the patient be disturbed as little as possible, and if she is much 
exhausted she should be allowed to rest for a short time before anything is done. 
The head should be kept low and the patient not allowed to turn on the side, 
since she might assume the Sims position, which favors the entrance of air into 
the uterine sinuses and possibly air embolism. The management of the puer- 
perium consists chiefly in: (1) cleanliness and (2) rest. In regard to cleanliness, 
the woman should be aseptic when she enters the lying-in bed; and after labor 
she should be kept as aseptic as possible. In regard to asepsis before labor,, 
it is taken for granted that the pregnant woman has found the daily habit of 
general bathing, cleansing the mouth, and external genitals. 

1. Asepsis during the Puerperium. — In ordinary cases the resources of nature 



RETENTION STRAP 

--r 




Fig. 936. — Abdominal Binder and Breast Support for the Normal Puerperium. 
The retention straps connecting the lower edge of the binder to a band about the thighs 
are used only when the binder shows a tendency to slip up above the pelvis. — {From 
a photograph.) 

cannot be equaled by those of art. I have noted the importance of limiting vaginal 
examinations as much as possible in the first and second stage, and the danger of 
unnecessary manipulation in the third stage. No physician is competent to 
manage a case of labor who cannot in the great majority of cases so conduct the 
third stage that no internal manipulations are necessary. The same principles 
of treatment should guide him in the management of the puerperium. Douches 
are not indicated unless unfavorable symptoms arise; e. g., high temperature or 
local fetor. (See Treatment of Septic Infection, Part VII.) Cleanliness of the 
patient and bedding, strict antisepsis of the external genitals, including disin- 
fection of lochia and thorough ventilation of the lying-in room, are important 
points to be remembered. (1) Antisepsis of the external genitals: This is best 
secured by washing with sublimate 1 : 4000, lysol solution (2 per cent.), and pay- 
ing special attention to the flexures of the thighs or any folds or creases of skin 
which may serve as receptacles for septic material. The lips of the vulva need not 
be separated; all washing should be done from above downward and the tissues 
about the anus should be scrupulously avoided till all the other parts are cleansed. 



750 PHYSIOLOGICAL PUERPERIUM. 

This cleansing of the external genitals should precede each application of the 
vulval dressing, and is best accomplished by vulval irrigation (Fig. 939) supple- 
mented with sterile cotton wipes. In all cases internal douches or other internal 
manipulations, especially by the nurse or others, in the absence of a distinct 
indication, are to be absolutely forbidden. There are always some abrasions 
and small wounds in the genitals which if not treated antiseptically may become 
the starting-point of an infection ; it is therefore necessary to conduct the valval 
dressing with strict attention to these details. (2) The vulval dressing rThere 
are three essentials of a vulval dressing: (a) It should be of absorbent material, 
that the accumulation of lochial discharge about the vulva may be prevented; 
(6) it should be saturated with an antiseptic material that the discharge may 
be sterilized; (c) it should be impermeable, that the air may be excluded. As 
an absorbent, gauze or cotton may be used, and should be borated or salicylated; 
sublimate is too irritating for this purpose. Deodorizing chemicals, or those 
with any odor, should not be used on the vulval dressing, as these mask- the 
fetor of decomposing lochia, a valuable sign of early septic infection. Over the 
vulval dressing a long strip of salicylated cotton wrapped in gauze should be 
placed and attached in front and behind to the abdominal binder. The vulval 
dressing should be changed every four to six hours. While the foregoing pre- 
cautions cannot be carried out in every case, it is fortunately true that if the 
vaginal examinations in the first two stages of labor are made with great 
care as to asepsis and limited as to number, if internal manipulations are care- 
fully avoided during the third stage, and if strict cleanliness of the patient and 
bedding is observed, very good results can be obtained even in the most un- 
favorable surroundings. 

2. Rest. — The first and most important requisite is that the patient should 
have a period of refreshing sleep. She may be allowed to see her husband or 
mother for a short time if she desires, but all other visitors should be rigidly 
excluded. She should not be disturbed by the congratulations of friends 
nor the intrusions of the curious, and if it is impossible to exclude them she 
should not know of their presence in the house, nor should she be disturbed by 
the crying of the baby. The room should be darkened and perfect quiet ob- 
served. It cannot be too often repeated that perfect cleanliness and absolute 
physical and mental rest should usher in the puerperium. The nurse, however, 
should from time to time note the pulse and general aspect of the patient, and 
the presence of uterine contractions. The exclusion of visitors and the ob- 
servance of quiet should not be limited to the first day or few days, but should 
continue at least as long as the patient is confined to her bed. 

3. Professional Visits. — The patient should be seen again within twelve 
hours after delivery, or sooner if required by the frequency of the pulse, rise of 
temperature, excessive flowing, or any other unfavorable symptoms. Morning 
and evening visits may be made for the first two or three days, and daily visits 
till the tenth day or later, the patient being kept under observation till involu- 
tion is complete. At each visit attention should be paid to (1) the mother's tem- 
perature, pulse, and respiration (a.m. and p.m.); (2) the height and condition 
of the uterus; after-pains; (3) the quantity, odor, and character of the lochia; 
(4) the condition of the external genitals; (5) the condition of the bladder; 
(6) the condition of the bowels; (7) the condition and secretion of the breasts; (8) 
the nipples; (9) diet; and (10) the general condition of the patient and the neces- 
sary treatment if any is required. Note should also be taken of (1) the child's 
temperature, pulse, and respiration, but it is unusual to take the infant's rectal 
temperature except for special indications; (2) the condition of the stump of the 



THE MANAGEMENT OF THE PUERPERIUM. MOTHER. 751 

cord and the umbilicus; (3) the number and color of the stools; (4) the passage 
of urine; (5) the color and condition of the skin; (6) the condition of the eyes 
(inflammation) ; (7) maternal nursing or artificial diet; (8) the stomach as shown 
by vomiting; (9) the weight; (10) the condition of the nose and mouth; (11) the 
general condition as to sleep, excessive crying, colic, irritation. For the care of the 
newly born infant, see Part VIII. (1) Temperature, pulse, respiration: A diurnal 
record should be made of the temperature and pulse, and when the latter is taken 
by the attending physician it is advisable to note its rapidity both at the begin- 
ning and at the end of his visit. Any departures from the normal standard should 
call for rigid investigation into the cause. (See Part VIII.) These three condi- 
tions should all return to normal on the second day in normal cases. The pulse 
is accelerated during and immediately after delivery and the temperature may 
show a moderate rise during the first thirty-six hours, but after that any elevation 
of temperature should be regarded with suspicion (Part VIII). (2) The height 
and condition of the uterus: The height of the uterus above the symphysis should 
be estimated or measured; and the sensitiveness and contractility determined 
by abdominal palpation, not neglecting at the same time to search for evidences 
of perimetritis or parametritis by palpating over the adnexa and in the iliac 
fossae. After-pains: These are caused by irregular and painful uterine contrac- 
tions, and are often due to clots in titer 0. The use of the fluid extract of ergot, 
one drachm every three hours, is usually beneficial in cases of retained blood- 
clots. Should the sleep be much disturbed, codein in moderate doses, one- 
quarter grain every two hours for two or three doses, may be used as less likely 
to produce unpleasant after-effects than other preparations of opium. De- 
pressants should be avoided. When pain is moderate and not due to blood- 
clots, phenacetin, five grains every three hours for two or three doses, will be 
found useful. I have found antipyrin, five grains, with a teaspoonful of aromatic 
spirits of ammonia every hour for two or three doses, efficient. When the pain 
is severe and not due to retained clots, the following will answer well: Tincturae 
opii deodoratae, 5i; chloralis hydratis, gr. xl; elixiris aromatici q. s. ad 5i. 
Sig. : Teaspoonful in water not oftener than every four hours. (3) The lochia: 
The physician should not neglect to inform himself as to the amount and char- 
acter of the lochia. Marked diminution or suppression or the presence of a 
putrid odor should lead to the suspicion of sepsis and a careful investigation. 
If the red color persists much longer than usual, it is probably due to subinvo- 
lution (page 767). The lochial stain in healthy cases is red in the center, gradu- 
ally fading away toward the periphery. In cases of putrid lochia the circum- 
ference of the stain is well marked.while the color at the center is lighter. Famil- 
iarity with the sometimes heavy but not offensive odor should be cultivated 
in order to avoid mistakes. (4) The external genitals: Antisepsis of the external 
genitals has already been referred to (page 749). (5) The bladder: A frequent 
and annoying complication of the puerperium is the retention of urine, of which 
the causes have been noted (page 736). At his first visit the physician should 
satisfy himself by percussion and palpation as to the condition of the bladder. 
The use of the catheter should be avoided if possible and urination encouraged 
by the application of hot cloths to the abdomen and vulva, by small doses of 
ergot and the sound of running water, by tightening the binder or compressing 
the abdomen to reinforce the action of the lax walls. The patient may succeed 
after the first three days, by the cautious assumption of the sitting posture. 
The dangers of sitting up at this time have been very much exaggerated, and 
if the uterus is well contracted and the pulse not affected by the position it is 
probably preferable to the passage of the catheter. It should be remembered 



752 PHYSIOLOGICAL PUERPERIUM. 

that the danger of cystitis from the passage of the catheter is decidedly in- 
creased after the second or third day on account of the beginning decomposition 
of the lochia. As a rule, the patient may be allowed to hold water for twelve 
hours if the uterus is well contracted and there is no danger of hemorrhage, and 
she should be encouraged in the effort to avoid the catheter. If its use becomes 
inevitable, it should be passed with all aseptic precautions. The external genitals 
should be carefully cleansed, the region of the meatus should be sponged with 
a i : 4000 sublimate solution, and the catheter inserted under the guidance of 
the eye. A glass catheter should be used when possible, as it admits of perfect 
sterilization by boiling. It is a useful precaution for women during the last few 
weeks of pregnancy to become accustomed to urinating in the recumbent posture. 
(6) The bowels: A laxative should be given at the end of the first forty-eight 
hours. Castor oil, from one-half to one ounce, if not offensive, is preferable. Com- 
pound licorice powder is a good preparation. When the patient feels an incli- 
nation for a movement, it is well to soften the rectal contents by an injection 
of two or three ounces of olive oil or water, since owing to the bruises and small 
lacerations incident to labor, the passage of hard fecal masses is sometimes very 
painful. The same procedure is valuable in perineorrhaphy cases (Part X). A 
laxative may be given from time to time while the mother remains in bed, but 
if enemata are sufficient they are preferable. Many women are unable com- 
pletely to empty the bladder or bowel by the use of the bed-pan, and resulting 
pelvic congestion and pressure are favored. The difficulty could have been 
avoided had the patient been trained in the use of the bed-pan during preg- 
nancy. Another remedy for incomplete bladder or bowel evacuation, and a 
method which at the same time favors uterine drainage, is permitting the patient 
to sit upon the vessel placed in the bed or upon a commode at the bedside, early 
in the puerperium, for bladder and bowel evacuation. This has in the past been 
recommended by some in selected cases, and by others in all. In my observa- 
tion during the past ten years on many thousands of cases confined in the tene- 
ments, I have never seen dangerous symptoms result from this practice, and 
yet the majority of patients within six or eight hours of their confinement either 
sat upon a vessel in bed or at the bedside to pass urine. (7 and 8) The breasts 
and nipples: The management of the nipples during the latter months of preg- 
nancy in cases of deficient development has been mentioned (page 194). With 
the establishment of the milk secretion on the third day the breasts sometimes 
become the seat of painful distention, owing to the excessive secretion, and the 
relief afforded by putting the infant to the breast may not be sufficient to relieve 
the condition. One of the best methods to correct the overdistention is massage 
and milking the breasts through a piece of hot sterile flannel, the milk being 
allowed to flow into the warm flannel (Part VII) (Fig. 982). Breast-pumps are 
to be avoided if possible, but if used the action should be assisted by the nurse, 
who should gently compress the breast and massage it with the finger-tips from the 
periphery toward the nipple (Figs. 982, 983, 984). All rough handling should be 
avoided. Uniform compression and considerable relief may be afforded by the 
use of a breast bandage, with or without hot stuping (Fig. 987 ). If the distention 
is very great, it may be advisable to administer a saline cathartic and restrict the 
supply of liquids, milk included, for a time. The application of a hot lead and 
opium wash may afford relief, but great care should be taken when applying the 
child to the breast. Before and after each nursing the nipples should be care- 
fully cleansed with a saturated solution of boric acid and covered with sterilized 
gauze without exercise of pressure. It is a useful precaution against cracks and 
fissures of the nipple to anoint the nipple and tissues about its base with steril- 



THE MANAGEMENT OF THE PUERPERIUM. MOTHER. 753 

ized sweet oil after each nursing. The importance to both mother and child of 
the proper performance of the function of lactation is universally admitted. 
Its favorable influences upon uterine contraction and involution and the subse- 
quent prevention of uterine disease should never be forgotten. 

4. Diet. — Individual characteristics must be considered, also the character of 
the delivery and whether it was accompanied with little or great loss of blood. 
A mixed diet seems to give the best results and may be begun on the first day. 
This form of diet causes the least loss of weight. During the first few days 
it is well to give a highly albuminized diet, and alcoholics should not be used 
except in the presence of collapse or weakness. Milk, wheaten and other 
forms of bread, soups, and well-cooked meats form the basis of the diet. Until 
the bowels have moved on the second or third day a light diet is advisable. 
Milk, milk-toast, soup, gruel, or clam-broth may be given. A small amount 
of tea may be allowed if the patient is accustomed to its use and desires it. 
Coffee is apt to cause insomnia. After the bowels have moved, the appetite 
of the patient may be trusted as a safe guide. The starvation diet is obsolete. 
In view of the amount of disintegrated tissue to be eliminated, it would seem 
that an excess of nitrogenous food is not indicated. Articles which cause con- 
stipation should be avoided. If the breast secretion is deficient, however, a 
liberal quantity of milk is the best remedy. 



Diet-list After Normal Confinement. First Day or Two. 

Liquids. — Milk, hot or cold; beef -tea, weak tea; beef-broth or chicken-broth; 
beef -juice; egg shake; clam-broth; simple soups and cocoa. 

Solids. — Thin bread and butter; saltine or soda crackers; milk-toast; dry or 
buttered toast; dropped or soft-boiled eggs; any breakfast cereal thor- 
oughly cooked. 

After First Two Days. — Liquids as above with addition of coffee. Solids: 
Any breakfast cereal; scrambled, soft-boiled, or dropped eggs; broiled 
white fish; lamb chop; beefsteak; roast lamb; broiled, baked, or creamed 
chicken; baked, mashed, or stewed potatoes; macaroni; celery; lettuce; 
fruits; fresh vegetables, such as peas, asparagus, and string-beans in season 
and in moderation; boiled or baked custard; curds and whey; wine jelly; 
simple puddings, such as rice, tapioca. Avoid: Nursing .mothers should 
avoid whatever previously disagreed with them, and usually also pork, 
veal, corned beef, cabbage, turnips, cucumbers, corn, beans (canned and 
dried), vinegar, strawberries, and melons unless thoroughly ripe. 

Sample Breakfasts. — (1) Any breakfast cereal; soft egg; tea. (2) Orange; 
cereal and cream; scrambled egg; tea or cocoa. (3) Cereal; broiled 
whitefish; bread and butter; tea, coffee, or cocoa. (4) Lamb chop; 
stewed potatoes; toast; tea, coffee, or cocoa. (5) Orange; scrambled or 
dropped egg; minced chicken; graham bread; coffee. 

Sample Dinners. — (1) Broiled or roast chicken; sweet potato; baked cup 
custard. (2) Roast lamb; mashed potato; macaroni; wine jelly. (3) 
Roast beef; celery; mashed potato; rice pudding. (4) Simple soup; 
chicken; stewed potatoes; baked cup custard. (5) Raw oysters with 
any of the above. 

Sample Suppers. — (t) Creamed chicken on toast; milk or cocoa. (2) Oyster 
stew; bread and butter; cocoa. (3) Minced chicken on toast; bake 
apples and cream; tea. (4) Dropped eggs on toast; graham bread and 
butter; cocoa or tea. (5) Raw ovsters with anv of the above. 
48 



754 PHYSIOLOGICAL PUERPERIUM. 

5. Posture and Duration of the Puerperium. — For the first few hours after 
labor the pillows should be removed and the head kept low to guard against 
the occurrence of cerebral anemia. For a day or two, and especially when the 
binder is not in place, the patient should on no account be allowed to turn 
on her side, for reasons stated (page 749). For the first two or three days 
the patient should remain quiet, lying on the back, which position is most 
favorable for the closing of the uterine sinuses, the healing of abraded surfaces, 
and escaping lochia. She should retain the recumbent position in bed until 
the uterus can no longer be felt by external palpation; that is, ten days or 
two weeks. The practice of keeping the patient on her back for all of this period 
is not to be recommended. It is unnatural and depressing, and tends to cause 
posterior displacement of the uterus, sacculation, and interference with drainage. 
After the first seventy-two hours the patient should be encouraged to turn 
first on one side and then on the other, and later to lie on the abdomen, and 
finally to sleep in this position. At the beginning of the third week the patient 
may be lifted into a reclining chair or on a sofa, and may sit up for a short 
time each day as her strength permits. After the fourth week she may go 
about the house or drive in the open air, but on no account should she resume 
her household duties or do any lifting, long standing, or walking until the 
period of involution is complete. The physician will not only do his duty 
to his patient, but will save himself subsequent reproach, by insisting on 
the observance of these rules, and he will find that every intelligent patient 
will submit willingly to restraint or inconvenience if he explain to her how 
largely her future health or even life may depend on care and moderation 
during the lying-in period. Getting up too soon, and especially too early 
resumption of household duties, are important factors in the production of 
displacements and even prolapse, particularly when delivery has been at- 
tended by some lesion of the pelvic floor which has been neglected or im- 
properly treated. Patients even after leaving the bed should spend part 
of each day in the recumbent posture, and the occurrence of a backache 
should be regarded as a warning against standing or walking and against any 
kind of work. One reason why the puerperal woman is better for a considerable 
rest in bed after delivery, and why the same kind of rest is not necessary in 
the case of quadrupeds, is that in the erect posture natural to human beings 
the uterus and its appendages and the floor of the pelvis are subjected to a 
downward pressure which does not occur in a quadrupedal position. When 
the woman does not rest recumbent long enough after delivery, she is liable 
to many forms of uterine displacement, and her too early getting up may cause 
hemorrhage by dislodging clots from the uterine sinuses, or thrombosis may 
occur in the veins of the broad ligament with danger of embolism in the heart 
or lungs. The duration of the rest in bed is variously given as seven, fourteen, 
to twenty-one days. The first is too short except in very unusual cases. A 
rest of two weeks followed by gradual resumption of ordinary activities is 
the usual period required. Involution of the uterus is not completed for a 
period of five or six weeks, but if a patient is kept in bed as long as that she 
loses flesh and strength and her appetite fails. When the patient first gets 
up, she should remain up only an hour or so in the day. 

6. Prophylaxis in the Puerperium. — While we cannot be so aggressive in 
our methods in the puerperium as in labor, yet there is much that may be 
accomplished in the way of prophylaxis. The all-important question at this 
time is, How can we best secure involution in the puerperal state? It is during 
the puerperium that we should rivet our attention on the prevention of sub- 
involution, especially in cases following the premature interruption of preg- 



THE MANAGEMENT OF THE PUERPERIUM. MOTHER. 755 




nancy. Were closer attention given this subject in practice, the sequelae 

of subinvolution — metritis, 

endometritis, retrodis- 

placements, and prolapse 

— would be less frequently 

met with. 

(i) The Abdominal 
Binder. — The proper treat- 
ment of the relaxed ab- 
dominal walls after de- 
livery is of great impor- 
tance for cosmetic reasons 
and to prevent the results 
of pendulous abdomen. A' 
certain amount of fixation 
is necessary for proper 
involution of the abdomi- 
nal walls, and this is best 
secured by a binder. 
While the patient is upon 
her back it is not neces- 
sary to have the bandage 
too tight, but it is advis- 
able to tighten it when 
she gets up. The binder 
tends to prevent atony 
and lack of contraction in 
the uterus, splanchnoptosis 
of the abdominal viscera, 
and obviates the danger 
of sudden filling of the 
abdominal veins due to 
the greatly lessened intra- 
abdominal pressure after 
confinement. The binder 
when properly applied con- 
duces to the patient's com- 
fort, especially by permit- 
ting her to assume the 
lateral position. It should 
not be applied too tightly, 
as this, combined with pro- 
longed dorsal decubitus, 
tends to cause posterior 
displacement of the uterus. 

(2) The Pelvic Binder. 
— After the patient begins 
to move about, the ordi- 
nary abdominal binder is 
with difficulty kept in 
place, and, moreover, by 







/ 



Fig. 937. — Pelvic Binder and Pelvic Floor Sup- 
port for Use after the Puerperium.* — {From a 
photograph.) 



* These binders may be obtained from the Home Bureau, 15 West 426. Street, New 
York Citv. 



756 



PHYSIOLOGICAL PUERPERIUM. 




this time has pretty much served its purpose. At this time in all cases, but 
especially in those of undue pelvic-floor projection, and in patients with weak 

and overdistended abdominal walls (tw T ins, 
hydramnios), I am accustomed to replace 
the abdominal with a pelvic binder, to sus- 
tain the pelvic floor and the antero-lateral 
abdominal wall for three months following 
the puerperium (Figs. 937, 938, and 939). 
The binder is made of muslin, linen, mull, 
canton flannel, or two thicknesses of heavy 
gauze, and, as the illustrations show, is made 
to encircle the pelvis and lower abdomen at a 
level with the crests of the ilia and to support 
the pelvic floor 'by a strap of the same 
material passing between the thighs, and, 
tightly drawn, is pinned in front or behind as 
convenient. Ordinary corset lacing down the 
front or back secures a snug fitting 'to the 
binder. The pelvic binder, when applied, 
laced, and the perineal band secured, is not 
unlike in appearance and shape the ordinary 
swimming trunks worn by bathers. I am 
accustomed to have half a dozen pelvic 
binders fitted and made in the latter part 
of the puerperium and to replace the use 
of the abdominal binder with them as soon 
as the lochia has practically ceased in the 
third week, when the patient first com- 
mences to sit up in bed or changes from bed to lounge, and to continue its 
use for three months from that time. The 
results obtained by the use of this support, 
have been more than satisfactory. It is 
appreciated by the patients themselves, 
some having used them after four confine- 
ments. (1) It prevents or corrects undue 
sagging of the pelvic floor. This is espe- 
cially noticeable in cases in which during 
labor the levator ani muscle has been sub- 
jected to severe or prolonged pressure, 
severe lacerations with bad union, and in 
which the levator ani is torn, the perineum 
remaining intact. (2) It assists in the 
ultimate union of severe lacerations of the 
pelvic floor which have been repaired. (3) 
It preserves the woman's figure after con- 
finement by its support of the low T er ante- 
rior abdominal wall and the pelvic floor. 
(4) It lessens the danger of displacement 
of the pelvic contents. (5) It tends to 
prevent pelvic congestion. (6) It usually 
adds to the comfort of the patient, giving 
her a feeling of security and well-being and 



Fig. 938. — -Pelvic Binder and Peri 
neal Support. Posterior View. 




BAC^ 
VIEW. 



Fig. 939. — Pelvic Binder and Peri- 
neal Support, showing Shape. 



THE MANAGEMENT OF THE PUERPERIUM. MOTHER. 757 

allowing her to obtain needed exercise earlier and more freely than would 
otherwise be the case. Unless preexisting pelvic disease is present, with 
the use of this pelvic support we rarely see the danger signals of pelvic con- 
gestion — backache and irritable bladder; and the complex nervous manifesta- 
tions of splanchnoptosis in general and of gastroptosis, nephroptosis, and 
enteroptosis in particular. 

(3) Medication. — What place have drugs and various non-medicinal methods 
of treatment of the puerperium in the prevention of subinvolution and subse- 
quent gynecological conditions? During the past ten years I have experimented 
with various methods of managing the puerperium with the object of deter- 
mining, if possible, the best treatment for the prevention of subinvolution 
and subsequent gynecological conditions. Ergot, quinine, repeated hot vaginal 






k 




Fig. 940. — Breast Support for Nursing 
Women. — (From a photograph.) 



Fig. 941. — India Gauze Bodice used as 
Breast Support. — (From a photograph.) 



irrigations, apparently have no effect in hastening uterine involution. The 
best results were obtained with (1) strychnin administered both during the 
latter part of pregnancy and during the first ten days of the puerperium; (2) 
rotation of the patient as regards posture during the lying-in state; (3) early 
use of the vessel in bed or the commode at the side of the bed, favoring drainage 
and avoiding pelvic congestion. 

(4) Massage and Exercise. — Massage, including dry friction of the skin 
of the whole body, general massage with deep manipulations, kneading and 
deep rubbing, local massage of the abdominal viscera, through the abdominal 
walls, and exercises, including principally passive and resisted movements 
of the extremities, are valuable therapeutic agents in the prevention of sub- 
involution of the uterus and abdominal walls, and splanchnoptosis with its 






758 PHYSIOLOGICAL PUERPERIUM. 

attendant digestive, circulatory, and nervous phenomena. Like other remedial 
agents, such measures are to be used with care, and are not applicable to all 
cases alike. Stimulation of the cutaneous circulation by dry friction with 
the hand or Turkish glove or by an "alcohol rub" can generally be used 
with advantage after the first day of the puerperium. In the absence of com- 
plications, general massage with deeper manipulations, kneading, and rubbing 
can be gradually introduced toward the end of the first week if the lochia 
is not increased thereby, and in the second week gradually increasing passive 
and resisted movements of the extremities may be added. All forms of septic 
infection, but especially the thrombotic variety, are contraindications to the 
use of anything more active than surface stimulation. 

(5) The First Use of the Corset. — It is especially important in the first use 
of the corset that a properly fitting garment be employed. At this time espe- 
cially should the corsets which exert a downward pressure into the pelvis, and 
form excessive pelvic floor projection, retro displacement, and prolapse of the 
uterus, be avoided. Corsets made to support the lower abdomen with an upward 
and backward pressure should be used (Figs. 36 and 37). 

7. The Examination of, the Puerperium. — The importance of routine examina- 
tion of the pelvic contents and noting the tonicity or sagging of the pelvic floor 
(levator ani muscle) at the completion of the puerperium cannot be overesti- 
mated. If this is made a routine, many minor derangements could be corrected, 
which, if untreated, would become aggravated by time. A routine physical exam- 
ination of every woman toward the close of the puerperium and before she passes 
out of the observation of the obstetrician is of the greatest value in detecting 
departures from the normal process of involution and in drawing attention 
to them when they are amenable to treatment. Were some simple, orderly 
method of history-keeping in obstetric cases in private practice adhered to, this 
examination in the puerperium would readily become a routine and give us valu- 
able records for subsequent reference. (See Appendix.) The following obser- 
vations should be made: (1) Height and position of the fundus uteri ; (2) con- 
dition of the breasts and nipples ; (3) condition of the pelvic floor, perineum, 
and ostium vaginae; (4) quantity and quality of the vaginal discharge; (5) 
position, sensibility, and mobility of the uterus, (6) condition of the adnexa 
and perimetrium and parametrium ; and (7) general condition of the patient. 



PART SEVEN. 
Pathological Puerperiurru 



PUERPERAL HEMORRHAGES. 



II. 
III. 

IV. 

V. 

VI. 

VII. 

VIII. 

IX. 

X. 

XI. 
XII. 

XIII. 

XIV. 

XV. 



. Constipation. 2. Tympanites. 3. Hem- 
2. Incontinence. 3. Retention. 
. Subinvolution. 2. Super- 



INTESTINAL ANOMALIES, 
orrhoids. 

URINARY ANOMALIES. 1. Hematuria. 
4. Cystitis. 5. Pyelonephritis. 

ANOMALIES OF THE GENITAL TRACT, 
involution. 3. Uterine Displacements. 

ANOMALIES OF THE PELVIC ARTICULATIONS. 

DIASTASIS OF THE ABDOMINAL MUSCLES. 

MORBIDITY IN THE PUERPERIUM. 

ANOMALIES OF THE BREASTS. 1. Absence of Mammse. 2. Hyper- 
trophy. 3. Supernumerary Breasts. Polymastia. 4. Anatomical Anom- 
alies of the Nipples. 

ANOMALIES OF THE MILK SECRETION. 1. Deficient Secretion. 2. 
Excessive Secretion, Polygalactia, Hyperlactation, Galactorrhea. 3. Qual- 
itative Anomalies. 

DISEASES OF THE BREASTS. 1. Areolar Inflammation. 2. Congestion 
and Engorgement. 3. Sore Nipples. 4. Inflammation of the Breasts, 
Mastitis. 



BLOOD CONDITIONS. 
3. Anemia. 



Thrombosis and Embolism. 2. Hematoma. 



DISEASES OF THE NERVOUS SYSTEM. 1. Lesions of the Sacral Plexus. 
2. Puerperal Neuritis and Paralyses. 3. Hemiplegia and Aphasia. 4. 
Myelitis and Paraplegia. 5. Puerperal Insanity. 

SKIN DISEASES. 

GENERAL DISEASES. 

SUDDEN DEATH. 



I. PUERPERAL HEMORRHAGES. 

Definition. — Puerperal hemorrhages are those occurring any time from 
twenty-four hours after the completion of the third stage of labor until the 
period of involution is complete, namely six weeks. They are also called 
secondary or late hemorrhages. 

Frequency. — Puerperal metrorrhagia depends largely upon the management 
of the third stage of labor, and the care that the puerperal woman receives 
during the first few hours of the lying-in stage. Secondary hemorrhage is 
not nearly so frequent as the primary post-partum hemorrhage. The amount 
of lochia varies in different patients. In some the duration of the lochial 
discharge is longer and its quantity greater than in others, and still it is not 
abundant enough to amount to a secondary or remote post-partum hemorrhage. 
True secondary hemorrhage is generally sudden. The quantity of blood varies 
and the bleeding may cease for a time and then recur. As in primary post- 
partum hemorrhage or flooding, so in the secondary variety, the hemorrhage 
may be entirely unlooked for, and may occur suddenly without premonitory 
symptoms of any kind. The first sign is the external flow of blood. The 
abruptness of its onset may preclude any opportunity for consultation, and 
if previous preparation for such an emergency has not been made, the result 
may be fatal. Besides the hemorrhage, there is often a fetid discharge resulting 
from decomposition of the retained parts. There may also be septic symptoms, 
which will offer an additional diagnostic point. 

Etiology. — The causes of secondary hemorrhages may be conveniently divided 
into general and local. Among the general causes may be classed : (i) Disturb- 
ances of the general circulation, such as occur in certain abnormal conditions 
of the heart, lungs, or liver, and result in the damming back of the blood into 
the pelvic vessels, or from the overuse of chloroform or stimulants; (2) acute 
infectious diseases; (3) peculiar blood conditions, as in puerperal fever, albu- 
minuria, and general malarial poisoning; (4) mental emotions, surprises, shocks, 
joy, anger, fright, such as fire in the immediate neighborhood, explosions, or 
sudden approach of an intoxicated husband, producing vasomotor changes 
or a relaxation of the uterus. Among the local causes are: (1) Uterine relaxa- 
tion; (2) retained placenta or membrane; (3) retained blood-clot; (4) a secon- 
dary placenta; (5) secondary hemorrhage from lacerations of the cervix, vagina, 
or vulva; (6) active pelvic congestion; (7) displaced thrombi; (8) metritis; (9) 
fibromata; (10) hematomata; (11) carcinomata; (12) uterine displacement; (13) 
distended bladder or rectum. 

1. Simple uterine relaxation is of rare occurrence as a cause of puerperal 
hemorrhage. It rarely occurs after the third day of the puerperium, and is 
usually caused by the retention of debris in the uterine cavity or by a defect in 
the control of the nervous system. 

2. Retained placenta or membrane results from careless management or 
an incomplete third stage of labor, and may usually be prevented by careful 
examination of the placenta and membranes at the time of labor, and removal 

761 



762 



PATHOLOGICAL PUERPERIUM. 



of retained fragments. Small pieces of retained membrane, it should be remem- 
bered, do not necessarily produce puerperal hemorrhage. This is the most 
important cause of secondary hemorrhage as well as the most frequent. Such 
a retention may be suspected if the lochial discharge is normal in amount and 
character at first, but becomes profuse and amounts to an actual hemorrhage 
after ten or fourteen days. The detachment of the retained placental fragments 
is apt to open one or more of the uterine sinuses. 

3. Retained blood clots are common in mul tip arse and may be prevented 
by careful watching of the uterus for one hour after the completion of the 
third stage. They are often secondary to retained placenta and membranes 
and to uterine displacement. The clots can usually be expelled by Crede's 
method. 

4. Secondary placenta, when it exists, may in like manner produce hemor- 
rhage. 

5. Secondary hemorrhage from lacerations of cervix, vagina, or vulva. 

Milder cases may be treated with 
plain hot water or acetic acid (two 
per cent.); more severe bleeding 
requires ligation. (See Part X.) 
The lacerations in the perineum and 
vulva are generally apparent, but 
sometimes those in the vagina are 
not visible without special examina- 
tion. Tears of the cervix some- 
times extend to the vaginal fornix 
and at times through a venous sinus. 
6. Active or passive pelvic con- 
gestion. Active pelvic congestion 
may be produced by moving about 
too soon after labor or by too early 
sexual intercourse. Passive con- 
gestion may result from subinvolu- 
tion, increasing and prolonging the 
red lochia, or may be due to ob- 
struction to the return circulation ; 
or it may come from varicosity of 
the pampiniform plexus or from 

disease of the adnexa. General diseases in this connection have been noted 

above. (See Postpartum Hemorrhage.) 

7. Displaced thrombi may occur primarily as the result of rapid heart 
action and high arterial tension following labor, or secondarily from septic 
disintegration of thrombi formed in the uterine sinuses. This accident may 
also occur from sudden strain, or from turning in bed or sitting up. 

8. Metritis. This inflammatory condition of the uterus sometimes makes 
it prone to bleed easily. (See Metritis, page 794.) 

9. Fibromata are liable to cause excessive and prolonged red lochia and 
may produce violent hemorrhage. Mucous polypi may also have the same 
effect (Fig. 942). 

10. A hematoma is an internal, interstitial, or concealed hemorrhage, which 
may be submucous, subcutaneous, or subperitoneal. As a rule, it does not 
require treatment.* 

* See N. Y. Obstet. Soc., April, 1901. 




Fig. 942. — Fibrinous Polypus of the Puer 
peral Uterus. — (Frdnkel.) 



PUERPERAL HEMORRHAGES. 763 

ii. Carcinoma is usually seated in the cervix and may require curettage 
and packing. Malignant disease of the uterus, as a rule, hinders or prevents 
conception, consequently this condition is rare. 

12. Uterine displacement may be caused by overdistended bladder, pro- 
longed dorsal position, getting up too early, or sudden effort on the part of 
the patient. Backward displacement is the most common. The heavy uterus 
is in a condition to be easily displaced and the direction varies widely. Any 
cause hindering the normal involution of the uterus tends toward this result. 
Immediately after labor the uterus is freely movable, and confinement of the 
patient to one position or the imperfect application of binders is most injurious. 
An abnormal flexion of the uterus will cause a retention of the secretions until 
the occurrence of putrefactive changes. Immediately after labor the normal 
position of the uterus is increased anteversion with a slight prolapse. When 
inversion takes place, it is usually very soon after labor, and may follow some 
severe strain. It must be differentiated from a polypoid tumor. Retroflexion or 
retroversion is often caused by the application of a tight binder before the uterus 
has returned to its normal position below the pubis, the pressure on the abdo- 
men forcing the organ backward. Subinvolution from any cause may produce 
this anomaly. Prolapse may occur from great straining, especially when labor 
has been attended by marked injuries. 

13. A distended bladder or rectum, especially the former, may act as a 
cause (Fig. 943). 

Symptoms. — These are general and local, the former being those characteristic 
of hemorrhage in general — pallor, weakness, dimness of vision, small, thready 
pulse, tendency to syncope, cold perspiration. The local symptoms are a soft- 
ened condition of the uterus and an internal and external hemorrhage, although 
at first the latter may not appear. 

Prognosis. — The amount of hemorrhage may vary within wide limits and 
the loss of blood may occur gradually or in a sudden gush. The great danger 
from puerperal hemorrhage lies in the opportunities for infection, which always 
threatens the puerperal woman, since the gaping vessels afford such an easy 
port of entry to septic products. 

Treatment. — This must vary with the cause. As in primary hemorrhage, 
the best treatment is preventive. All the general and local causes of the accident 
should be prevented, or if present they should be corrected. The lying-in 
woman should be protected against (1) mental emotions; (2) disturbances of 
the general circulation ; and (3) blood conditions that might cause a hemor- 
rhage during the puerperal state. If the third stage of labor, as well as the first 
few days of the puerperium, is properly managed there will be avoided (1) 
the retention of placental tissues, (2) of membranes, and (3) of blood-clots, and 
(4) a distended bladder or rectum. The patient should be kept quietly in bed 
till involution is complete and sexual intercourse should be prohibited for two 
months. The curative "treatment of this condition consists, as in primary 
hemorrhage, in making sure that the uterus is completely emptied, and in 
securing complete contraction. A vaginal examination should always be made, 
and, if the cervical canal allow it, the uterine cavity explored and any retained 
material removed. If the cervix will not allow of the passage of the finger 
and the hemorrhage is profuse, the canal must be dilated and the interior of 
the uterus examined. Should the evacuation of the uterus not stop the bleeding, 
its interior should be swabbed out with a 2 per cent, acetic-acid solution — or 
the plan of irrigating the uterus with hot water at a temperature of no° F. 
may be tried. The contracted state of the cervix may prevent the proper 



764 PATHOLOGICAL PUERPERIUM. 

outflow of the water, and this must be guarded against by using a small intra- 
uterine tube or return-flow tube and first securing ample dilatation of the 
cervical canal. If there are symptoms of septicemia, creolin injections are 
excellent. Ergot, one to two drachms, with tincture of cannabis indica fifteen 
minims, is indicated and may be repeated as necessary. Rest, both physical 
and mental, must be insisted upon, while tonics and a nutritious liquid diet 
will be subsequently needed. If relaxation of the uterus is the cause, packing 
the uterine cavity with gauze is the best treatment. (See Part X.) This is 
also used in the case of sepsis or displaced thrombi. And here the curette 
must not be employed. Uterine polyps should be removed. Faradism is of 
some value. A hard bed and a cool room should be provided, and the rectum 
and bladder should be emptied by enema and catheter if necessary. 



II. INTESTINAL ANOMALIES. 

i. Constipation. — This is the rule in the puerperium, and is caused by weak- 
ened musculature of the abdominal parietes and intestinal muscle-coats and by 
the prolonged rest in bed. This condition often causes fever, possibly from the 
absorption of animal alkaloids. Evacuation of the bowels should occur by the 
end of the third day (unless there has been a complete suture of the perineum, 
when treatment should be deferred until the fourth day), and the administration 
of laxatives during this period is not necessary if the bowels were well opened 
before labor. But if no movement occurs in this time and diet seems to have 
no effect, it is well to try a simple injection of water, to which a little glycerin 
may be added. For not only the mother's condition must be taken into con- 
sideration, but, if she nurses her child, the latter demands equally careful con- 
sideration. If the injection is not effective, castor oil, calomel, a saline laxative, 
or the well-known combination of aloin, strychnin, and belladonna maybe given. 
The regular action is then generally established, although an obstinate constipa- 
tion may persist which will demand much skill to overcome.. 

2. Tympanites. — There sometimes occurs in neurotic women an excessive 
amount of gas in the intestines following a sudden paralysis of their muscu- 
lature. The abdomen is greatly distended, so that there may be true orthopnea 
from upward pressure of the diaphragm, and there is obstinate vomiting with 
persistent constipation and other signs of obstruction of the bowels. There 
are no symptoms of peritonitis, but there is a serious outlook for the patient's 
life, demanding radical treatment. Nerve sedatives, large hypodermic doses 
of strychnin, enemata of asafetida and turpentine, and gentle cathartics by 
the mouth are all indicated. If these measures fail, the rectal tube and high 
enemata may be used. 

3. Hemorrhoids. — Pregnancy may cause such a degree of congestion of the 
rectal veins that it may persist after labor. This condition may show itself 
only during the period of parturition or it may persist afterward. The pain 
is very severe. Ulceration and gangrene may result. In treating this con- 
dition the bowels must be kept regular, and either hot or cold local applications 
will relieve the pain. Astringent, sedative suppositories sometimes give relief, 
as belladonna, opium and lead, and compound ointment of gall. If strangu- 
lation occurs, the tumors must be excised. 



URINARY ANOMALIES. 



765 



III. URINARY ANOMALIES. 




fy 



C& 



ppq 



i. Hematuria. — This condition in the puerperium generally follows a hemor- 
rhoidal condition of the vesical veins induced by pelvic congestion in the last 
part of pregnancy. It may be due also to injury from pressure of the child's 
head or from instruments or the result of vesico-vaginal fistulas. The differential 
diagnosis may be made from the history. Blood when present in the urine 
generally disappears spontaneously in a few days, but occasionally astringent 
injections are necessary. Unusual care should be observed at this time in the 
use of the catheter. 

2. Incontinence of Urine. — Incessant dribbling may be due to paralysis of 
the sphincter or to fistulas. If the urine escapes involuntarily soon after delivery, 
an examination should be 

made at once. If there 
are also present severe 
abdominal pains and the 
urine escapes a few drops 
at a time, or with an oc- 
casional gush or spurt, 
there will be grounds for 
the diagnosis of inconti- 
nence of retention. Ex- 
amination will reveal a 
median abdominal tumor 
having a dull percussion 
note. The catheter will 
empty the bladder and 
relieve the distention. 
If, however, there is no 
pain on the escape of 
urine, and if labor has 
been abnormal, a fistula 
will probably be dis- 
covered. When this is 
very small, it may heal 
spontaneously. But if 
this is impossible, a plas- 
tic operation may be necessary later. Rarely pressure paralysis of the vesical 
sphincter and the urethra may be the cause of this trouble. Such cases some- 
times do not seem amenable to treatment of any kind, though tonics, elec- 
tricity applied to the urethra, and massage may be successful. 

3. Retention of Urine. — After labor retention of urine is very common, and, 
indeed, may be expected for a few hours. This is caused by the expansion 
of the bladder and its loss of sensibility after the uterus has expelled its contents, 
and often by the cessation of action of the abdominal muscles. There may 
also be a real obstruction from traumatism of the urinary apparatus, especially 
the urethra. Before resorting to the use of the catheter, which is always at- 
tended with some risk of bladder infection, all other known means for relieving 
the condition should be tried, as the sound of running water, allowing a stream 
of warm water to flow over the vulva into a douche pan, the application of hot 
chloroform stupes to the vulva, and, if not contraindicated, allowing the patient 





Fig. 943. — Retention of Urine and Distended Blad- 
der DURING THE EARLY PART OF THE PUERPERIUM. 



766 PATHOLOGICAL PUERPERIUM. 

to assume the sitting posture in bed on the vessel or douche pan. If this last 
procedure is permitted in the first twenty -four hours of the puerperium, the 
nurse should be instructed carefully to watch the fundus uteri during the evacua- 
tion of the bladder. Whatever the cause, a period not longer than eighteen 
hours should be allowed to pass before the patient is catheterized, and in 
this operation all possible antiseptic precautions should be taken. Retention 
is most common after suture of the perineum. The bladder may be injured 
by retention and uterine hemorrhage occur from the excessive distention of 
the organ. (See Puerperal Hemorrhage, page 761.) (Fig. 943.) 

4. Cystitis. — This is unfortunately quite common in the puerperium and is 
a serious affection of the urinary system to be guarded against, since it may 
lead to a fatal result. Frequently it does not pass beyond the mild form, 
and its duration is then only transitory. Etiology: The common cause is 
careless introduction of the catheter. This should always be done under 
the strictest antiseptic precautions. The urethral orifice should never be 
shielded by the bed-sheet, but ought in all cases to be perfectly exposed to 
the view of the operator. Again, though rarely, overdistention of the bladder 
or pressure of the child's head may injure the vesical walls sufficiently to cause 
a catarrhal c} r stitis. This type is generally of short duration unless an intro- 
duction of micro-organisms takes place. Under these circumstances the simple 
lesion may develop into a suppurative inflammation which does not limit 
itself to the bladder, but extends along the ureters to the kidneys and ends 
in disease of these organs. Even when the catheter is not used there may 
be migration of vaginal micro-organisms into the urethra, and, according to 
some authorities, micro-organisms from the various pelvic viscera may find 
their way into the bladder. Symptoms : The symptoms of the milder type are 
those of an ordinary cystitis: viz., frequent urination, discomfort, burning pain, 
and alkaline urine. With the development into the septic form, the symptoms 
increase in severity, especially with the extension of the disease to the ureters. 
Sometimes delirium occurs, the temperature is high, and anemia and prostra- 
tion are extreme. The constant desire to urinate gives rise to great distress. 
The condition of the bowels is quite variable. 

Urinary examination shows the amount to be small, the specific gravity 
low, reaction acid. The microscopic examination reveals epithelium of several 
varieties, pus- and blood-corpuscles, urates and uric acid crystals. The mucous 
membrane may exfoliate and pass off in the urine. In such severe cases the 
presence of albumin and tube casts will be detected. The prognosis of this 
affection will depend upon prompt attention and careful treatment. The great 
danger lies in extension to the kidneys. Prophylaxis is most important. After 
its occurrence the bladder should be irrigated several times a day with boric- 
acid solution; creolin, 0.5 per cent., or sublimate, 1 : 20,000, is sometimes used. 
The internal administration of salol, boric or benzoic acid, and buchu is also 
advisable, as these drugs affect the quality of the urine. The patient's strength 
and general tone must be kept up by tonics and stimulants as well as by nourish- 
ing food. Subsequently change of climate is often beneficial. 

5. Pyelonephritis. — This may occur from the extension of the vesical lesion 
along the ureters to the pelvis of the kidney. There are cases in which the 
bladder trouble is so slight that it is not noticed, and it is only the lighting-up 
of the renal inflammation that draws attention to the disturbance. This 
infection may also be caused by the irritation of renal calculi or may occur 
from the blood. The prognosis is doubtful, many cases ending fatally. The 
treatment is essentially the same as in cystitis, with the addition oftentimes 



ANOMALIES OF THE GENITAL TRACT. 767 

of incision of the pelvis of the kidney or of the perinephritic abscess, in case the 
latter develops. Post-mortem examination has shown the kidney to be involved 
as a whole, forming a large bag of pus, or to be honeycombed throughout with 
tinv abscesses. 



IV, ANOMALIES OF THE GENITAL TRACT. 

I. Subinvolution. — Subinvolution is a retarded or incomplete involution of 
the uterus. The normal process requires generally from six to ten weeks. 
Pathology: The process of involution is one of fatty degeneration, absorption, 
and atrophy. It is not believed that the whole muscle cell is destroyed by 
fatty degeneration, but rather that atrophy accompanies the fatty process 
and ceases after the muscle fiber reaches its original size. The uterine adnexa, 
vagina, and vulva undergo the same process. (See Part VI.) It can readily be 
seen how slight influences, either acting directly on the uterus or through the 
mother's blood, can interfere with the process of involution, resulting in the 
pathological condition known as subinvolution. Arrested involution depends 
entirely upon changes in the circulation of the uterus or its vicinity ; congestion, 
either active or passive, being the important etiological factor. Etiology: (i) 
Causes interfering with the proper contraction and retraction of the uterine 
muscle or with its blood supply must be looked for as originating the condition 
of subinvolution. As a rule, these causes are local, though there are a few ex- 
ceptions. Among the local causes may be mentioned: habitual distention of the 
bladder or rectum, retained secundines, displacement of the uterus, fibroid 
or polypoid tumors, or old peritoneal adhesions. (2) Causes either increasing 
the blood-supply to, or obstructing the return flow from, the uterus are: 
inflammatory conditions subsequent to septic processes, fibroid and other 
pelvic tumors, retained hypertrophied decidua as in incomplete abortion. 
Endometritis from other causes, cardiac and pulmonary disease, inflammatory 
conditions interfering with pelvic circulation, and all the causes of obstructed 
portal circulation also belong under this head. Nervous disorders, such as 
puerperal insanity or a great shock, not infrequently effect involution. 
Too early sexual intercourse after abortion or delivery may not only 
hinder but arrest involution. Women who do not nurse their children 
are more prone to this abnormality. It has been held by some that 
constitutional disturbances having no connection with any local cause 
may furnish the etiological factor. The local cause, however, should al- 
ways be carefully looked for. Diagnosis: An early diagnosis is important, 
in order to avoid the numerous disorders which are so likely to follow sub- 
involution. Abdominal palpation will detect approximately any defect in the 
involution of the uterus; later, however, the diagnosis is generally made by 
the gynecologist. The uterus is large, boggy, soft, and tender on pressure. 
The size of the organ does not correspond to the period of the puerperium. 
Symptoms: These include a feeling of weight in the pelvis, lochia profuse and 
red, or serous lochia changing to bloody lochia late in puerperium, backache, 
reflex symptoms, pain or tenderness over the lower portion of abdomen. Irrita- 
ble bladder or rectum may be present if acute displacement exists. Treatment: 
The prophylactic treatment of subinvolution is most important to save the pelvic 
organs from various subsequent gynecological conditions. (See Management of 
the Puerperium, Part VI.) The curative treatment must depend upon the 



768 



PATHOLOGICAL PUERPERIUM. 



cause. If this is retention of placental or decidual tissue, the uterus should be 
curetted and disinfected. If there is laceration of the cervix or vagina, they will 
have to be repaired. Displacement of the uterus should be remedied by a suitable 
pessary, which is to be changed from time to time as the organ decreases in 
size. A pelvic tumor may be removed. The general functions of the body 
must be maintained by hygienic measures. Massage of the uterus may assist 
it to return to its natural size. When the amount of lochia is excessive, hot 
vaginal douches should be given. The pelvic viscera should be depleted by 
hot injections and vigorous catharsis. Ergot is sometimes employed when it 
seems especially indicated by muscular weakness or the presence of small 
fibroids. Tonics and electricity are at times beneficial. 

2. Superinvolution, Hyperinvolution. — A condition known as super involution 
or hyperinvolution, depending upon a prolongation of the fatty degeneration 
and atrophy of the parturient uterus, has been known to exist. It is very 
infrequent. In very rare cases the uterus may almost disappear. It is prob- 
ably the result of profound anemia; protracted lactation may coexist. The 
symptoms are usually not pronounced. Menstruation may not return. Diag- 



l/t.ves. p&rinenm 
Posterior Vag.tormx^ 
Corpus cavernosuntt Ou Clitoris, ^Nfl 
\fasels it at, clitoris- 

Urethra - 

AnwiorVcta. fornix _ 

Anterior cervical 'Lip~ 
' ina 
IntroiMs 




Rt Com. Iliac Artery 
Left Com. Iliac Vein. 



1st Sacral Vert 
Cervical Canai 
Fundus uteri 
Left Hornot i'term 
Rectum 



Anus J 
Internal sphincter 
External sphincter 



Fig. 944. — Retroflexion of the Puerperal Uterus in a Multipara. — (Sellheim.) 



nosis should be made by bimanual examination. For treatment, the child must 
be weaned, tonics administered, the diet made nutritious and generous, and 
hygienic measures instituted, such as a change of air and scene, with massage 
or carefully regulated exercises. 

3. Uterine Displacements. — (1) Inversion. (See Pathology of Labor, page 
647.) (2) Prolapse: The degree of this displacement varies to a great extent. 
When the injuries during birth have been severe, some great strain during 
the puerperium, such as lifting a heavy weight, causes occasionally a pro- 
lapse of the puerperal uterus. The latter is greatly increased in weight 
and deficient in muscular tone, both conditions favoring displacement. (3) 
Retroflexion and retroversion (Fig. 944): Retroflexion and retroversion are most 
commonly found in women who have suffered from these displacements before 
conception and in those who have aborted. A sudden strain, failure to empty 
the bladder when the desire is felt, and the use of tight binders, as noted 
before, may all contribute to these forms of displacement. These patients 
should stay in bed longer than usual and they should lie on the side as much 
as possible. In the latter part of the puerperium astringent douches should 
be given. (4) Anteflexion and anteversion: Extreme anteversion or anteflexion 



ANOMALIES OF THE PELVIC ARTICULATIONS. 769 

may also occur in the puerperium; the latter especially will cause a reten- 
tion of the uterine secretions. Other abdominal organs are also sometimes 
displaced during the puerperium; floating kidney may be mentioned as an 
example. 



V. ANOMALIES OF THE PELVIC ARTICULATIONS. 

The joints affected are the symphysis pubis and sacro -iliac synchondroses. 
The cause is sometimes pathological change, sometimes the violent use of the 
forceps, or a combination of the two. These joints, as has already been noted, 
become relaxed in normal pregnancy so that they allow a slight amount of 
movement of the bones on one another. Various etiological factors are men- 
tioned by different authorities, besides those noted above, among which are 
extreme exertion on the part of the patient, pressure of a large fetal head, 
and traumatism, which may cause inflammation. There is hyperemia and 
swelling of the synovial membrane and an increased secretion of the synovial 
fluid until the extremities of the bones become separated from each other. If 
this condition becomes more serious, the formation of pus takes place and abscess 
develops. The bone is gradually eroded and even becomes carious. Complete 
rupture of the joints of the pelvis may occur. Symptoms: These are noticed 
when the patient first gets up and tries to walk. There is pain, extending 
into the lower extremities, and increased mobility of the articulations. The 
latter fact can be proved by manual examination. The patient probably 
walks with difficulty. However, there may be considerable movement and 
little impairment of walking, or there may be slight movement only, with 
much pain and lameness. The gait is very like that of the osteomalacic patient. 
In case of suppuration the symptoms are greatly intensified, chill and fever 
come on, abscesses of the soft parts develop, and the patient becomes unable 
to move the legs. Relapse is not unlikely to occur in the next pregnancy. 
In rare instances septicemia or pyemia result. Diagnosis: This is easily 
made from a few characteristic symptoms. The pain can always be exactly 
located by the patient in the diseased joint. There is tenderness on 
pressure or motion. The usual symptoms of suppuration indicate its pres- 
ence. The prognosis is favorable in simple cases, but increases in gravity 
with the development of suppuration. Treatment: Rest in bed in the dorsal 
position and a strong, firm bandage, whose upper border is level with the iliac 
crests while the lower reaches just below the trochanters (Fig. 936). The 
patient may then walk around as she would ordinarily, even if there is pain. 
The condition generally terminates in recovery, the bones becoming fixed after 
some months, but, in a very few cases, this does not happen and the bandage 
has to be worn continuously. When the pain is severe, the ice-bag is indicated. 
Narcotics may also be given. The disease may become chronic, and in that 
case change of climate, sea-bathing, mild count erirritation, and continuous 
tight bandaging will be efficacious. 



VI. DIASTASIS OF THE ABDOMINAL MUSCLES. 

In patients whose abdomens have been unusually distended or whose 
abdominal muscles are weak, and especially in those who have borne many 
children, the recti are not infrequently separated. This condition sometimes 
49 



770 PATHOLOGICAL PUERPERIUM. 

allows the protrusion between the muscular borders of part of the abdominal 
contents, with the resulting symptoms of hernia. If properly reduced, the 
intestines may be quite easily held in place by means of a suitable bandage, 
and an operation subsequently performed. 



VII. MORBIDITY IN THE PUERPERIUM. 

Since the general adoption of asepsis and antisepsis by obstetricians severe 
puerperal morbidity has become of too infrequent occurrence for a single ob- 
server to be personally familiar with all its phases. As a natural result, the 
descriptions of these affections in standard works contain many contradictions, 
and it is by no means easy to obtain definite ideas as to the various manifesta- 
tions of infection and intoxication occurring in the puerperium. The data 
accumulated by Lenhartz, in his great monograph on septic affections, are by 
no means in harmony with the teaching found in the leading text-books on 
obstetrics. I have therefore tried to subject the entire matter of puerperal 
morbidity to a careful analysis, based upon the latest authoritative data and 
my own clinical experience, and to classify and describe the various types of 
disease in such a way as to eliminate some of the sources of contradiction and 
confusion. 

Frequency of Morbidity in the Puerperium. — The usual rough test between a 
normal and a pathological puerperium is furnished by the temperature. If 
the latter is over 100.4 F- (3 8° C.) in the axilla, the case is enumerated under 
morbidity. 

The morbidity of the Paris clinics is shown by the following figures compiled by Budin : 
Charite, 1891-1894, 10.7 per cent.; Maternite, second half of 1895, 12.8 per cent.; 1896, 
10.6 percent.; 1897, 10.6 per cent.; Tarnier's clinic, 1898, 8.93 per cent.; 1899, 12 per cent. 
These figures make the average morbidity nearly 1 1 per cent. The statistics of some of the 
leading German clinicians are as follows: Merman, 6 per cent, fever of over 100. 4 F. (38 C.) ; 
Leopold, considerable variation from year to year, limits from 8 to 20 per cent, approxi- 
mately, average 14.6 per cent.; von Szabo, 19.75 P er cent.; Zweifel, 17.4 per cent.; Hof- 
meier andSteffeck, 8.5 per cent.; Madlener, 18.6 per cent.; the average morbidity in these 
German clinics is therefore a little over 14 per cent. Ahlfeld, who has collated figures from 
many clinics, finds that the morbidity varies from 9 to 54 per cent. Such fluctuation 
appears to show that differentiation between puerperal and other fevers is very difficult. 

Sellheim believes that high and persistent temperature occurs in about 
2 per cent, to 4 per cent, of institutional cases. In an analysis of 2200 cases 
of confinement I found that a rise of temperature to 100. 4 F. (38 C.) or 
over took place in 405 cases, or 18.45 P er cen t- In 204 cases the fever con- 
tinued but a few hours, there being but a single elevation, and in only 72 of 
the 405 cases did the fever last for more than three days. In the 405 cases 
of fever the rise of temperature was: 



Due to constipation in 

" reflex irritation in 
complicating disease in 
neurotic condition in. . 



259 cases, 

42 
20 
1 " 


or 63.95 per cent. 

4-94 ' 
0.24 


55 
2 5 


79.50 per cent. 

' 13.58 per cent. 
6.92 
20.50 per cent. 



septic infection in 55 

"no assignable cause in 2 

This gives a morbidity percentage from non-septic conditions of 79.50 per 
cent.; from sepsis, of 13.58 percent.; and from unknown causes, of 6.92 per cent. 



MORBIDITY IN THE PUERPERIUM. 771 

Classification. — I believe this subject is best considered under three main 
headings: viz., (A) Morbid conditions of the puerpera which antedate labor. 
(B) Morbid conditions which result from labor. (C) Morbid conditions which 
originate or first appear in the puerperium. While it is customary to allude to 
many of the conditions presenting themselves under Divisions A and B as pre- 
disposing causes of puerperal morbidity, a little reflection will show that they 
themselves may represent morbidity of pronounced types. Conditions under 
division C are loosely spoken of as "puerperal infection," "puerperal fever," " pu- 
erperal sepsis," etc. Once regarded as manifestations of a single specific dis- 
ease, they are now known to comprise a variety of local and general conditions. 

CLASSIFICATION OF PUERPERAL MORBIDITY, 

(A) MORBID CONDITIONS OF THE PUERPERIUM wlilCH ANTEDATE LABOR. 

Acute: I. Acute Toxemia of Pregnancy. II. Antepartum Sapremia or Bacteriemia. 
III. Chance Infection with Acute Specific Diseases. Chronic: IV. Chronic 
Toxemia of Pregnancy. V. Chronic Toxemia, etc., not Due to Pregnancy. 
VI. Genital and Extragenital Inflammations. 

(B) MORBID CONDITIONS WHICH RESULT FROM LABOR. 

General: I. Shock and Extreme Fatigue from Dystocia. II. Acute Anemia from 
Hemorrhage. Local: III. Incomplete Labor. Faulty Contraction, Evacua- 
tion, and Drainage. IV. Birth Traumatisms. V. Changes in the Locality 
and Activity of the Bacteria of the Genital and Perigenital Regions In- 
duced by the Act of Labor and its Management. Migration. Inoculation. 
Mobilization. 

(C) MORBID CONDITIONS WHICH ORIGINATE OR FIRST APPEAR IN THE 

PUERPERIUM. 

Primary, Consecutive, and Metastatic Focal Infections. 
Primary Focal Infections. 
Genital: I. Puerperal Ulcers. II. Endometritis from Saprophytes. Putrid Endo- 
metritis. III. Endometritis from Pyogenic Bacteria. Simple Infectious 
Endometritis. IV. Endometritis from Mixed Infection. Composite Endo- 
metritis. Extragenital: V. Mastitis. 

Consecutive Focal Infections. 
Extension by Continuity: VI. Infection of Urinary Tract. VII. Proctitis. VIII. 
Salpingitis. Peritonitis. Extension by Lymphatics: IX. Metritis. X. Para- 
metritis. XI. Peritonitis. Circumscribed or Perimetritis. General. Ex- 
tension by Veins: XII. Metrophlebitis. Femoral Phlebitis. XIII. Specific 
Diseases. Gonorrhea. Diphtheria. Erysipelas. Miscellaneous. 

Metastatic Focal Infections. 
Blood States or General Conditions. 
Simple. 
I. Sapremia. II. Bacterial Toxemia. III. Bacteriemia. 

Composite Sepsis. 
IV. Bacteriemia with Toxemia. Septicemia. Pyemia. Septicopyemia. V. Sap- 
remic Sepsis. (Gas Sepsis.) 

Anomalies of Temperature. 
VI. Hyperthermia. VII. Fever. VIII. Hypothermia. 

(D) CLINICAL TYPES OF PUERPERAL MORBIDITY. 

The puerpera inherits from the~pregnant state any morbid condition from 
which she may have suffered during that period, whether called forth by preg- 



772 PATHOLOGICAL PUERPERIUM. 

nancy or not. While some of these conditions, especially those due directly to 
pregnancy, have a natural tendency to improve after delivery, others remain 
unaffected, and not a few tend to become worse; while conditions absolutely 
dormant are sometimes roused into being for the first time. The possible legacy 
of the puerpera must therefore always be borne well in mind. To conditions of 
this character must be added the shortcomings and accidents of labor itself, 
and the various readjustments rendered inevitable by the transition from preg- 
nancy to the puerperium. 

(A) MORBID CONDITIONS OF THE PUERPERIUM WHICH ANTEDATE 

LABOR. 

I. Acute Toxemia of Pregnancy. — This condition has been fully described 
under this head and that of eclampsia and pernicious vomiting. (Pages 346 
and 338.) In this connection we need only state that a woman delivered with 
eclampsia, acute yellow atrophy of the liver, or pernicious vomiting occurring 
late in pregnancy, is still in a very precarious condition, and emptying the 
uterus does not necessarily save her. If the toxemia is sufficiently intense she 
may perish of convulsions and coma, and this is almost invariably the result 
in cases of acute yellow atrophy; or if she survives, she may fall a ready victim to 
sepsis. According to Norris, the toxemia of pregnancy may attack the heart 
directly, so that the strain of labor causes acute cardiac failure during or after 
delivery. (Compare Toxemia of Pregnancy, Part III.) 

III. Antepartum Sapremia or Bacteriemia. — The local and general phenomena 
of ordinary puerperal infection and intoxication may develop before delivery. 
This is seen especially in arrested labor from non-engagement of the head, in 
which infection of the amniotic fluid occurs, and in death and putrefaction of 
the fetus in utero. It is of very frequent occurrence in attempted criminal 
abortion. Mere retention of the fetus may not cause morbidity as long as the 
membranes are unruptured. After infection of the uterine contents the woman 
may die of sepsis before the uterus is evacuated. If the uterus is emptied, the 
woman may begin her puerperium in a state of severe infection or intoxication. 
Generally speaking, the local and general conditions are the same as those to 
be described in sepsis, etc., which originates postpartum. Septic abortion is 
considered elsewhere (page 403). The subject of antepartum infection will be 
mentioned again under Clinical Types of Puerperal Morbidity. 

III. Chance Infection with Acute Specific Diseases. — The pregnant woman 
may contract any of the acute infectious diseases, such as typhoid fever, pneu- 
monia, variola, etc. All such affections, including acute poisonings with min- 
erals or drugs, are considered in their appropriate sections. We need only 
state here that such affections, when they do not prove fatal outright, tend 
to bring on abortion or premature labor, and to finish their course during the 
puerperium. (See Part III.) When they originate before delivery, they are not 
likely to be mistaken for puerperal sepsis. Their reaction upon the latter is not 
entirely known. Upon the principle of antibiosis, which is a somewhat rare 
phenomenon in clinical medicine, they might in theory sometimes protect the 
woman from septic accidents post partum ; but in general they should rather 
pave the way for an associate puerperal infection (symbiosis) by the ordinary 
pyogenic bacteria. Vinay shows that in many cases of severe infectious dis- 
ease death is really due to ordinary pyogenic sepsis; and such a termination 
is greatly favored by the incomplete character of the labor, which favors delayed 
expulsion, putrefaction of fetus, and retained placenta. 



MORBID CONDITIONS WHICH ANTEDATE LABOR. 773 

IV. Chronic — better Benign — Toxemia of Pregnancy. — This condition has 
been described under pathology of pregnancy. (Page 324.) Its persistence in 
the puerperium has received but little attention, probably from the fact that it 
is usually thought to subside promptly after delivery. But such an immediate 
subsidence of so complex a state is hardly credible. The best evidence of the 
persistence of this toxemia into the puerperium, is the occasional occurrence of 
postpartum eclampsia (page 346) and polyneuritis (page 375). If we regard 
the hyperinosis of pregnancy as allied to the toxic state, we must note the fact 
that this increases instead of diminishes during the puerperium. The resulting 
coagulability of the blood is responsible for the formation of aseptic thrombi, 
which, while they serve to plug patulous venous sinuses in an uncontracted 
uterus, also produce the benign form of phlegmasia dolens, and even cause at 
times fatal embolism. The thrombi which form in the uterine veins become 
readily infected in pyogenic endometritis. 

At least a week is required for the albuminuria of pregnancy to subside 
after delivery, and whenever this is present in the puerperium to a marked 
degree, we must fear the occurrence of late eclampsia. As long as albuminuria 
persists we should regard the toxemia of pregnancy as still present. When the 
bowels of the puerpera are left to themselves, a spontaneous movement does 
not occur until at the close of the first puerperal week. Such a condition 
directly favors the maintenance of a toxemia (stercoremia). Ewing (see Toxe- 
mia of Pregnancy, page 324) insists that many of the symptoms which make 
up the chronic toxemia of pregnancy are prolonged throughout the period of 
lactation. Personally he has no doubt that it is a strong predisposing cause 
of puerperal sepsis; that it may be, in fact, an active expression of this con- 
dition. 

V. Chronic Toxemias not Due to Pregnancy. — Here belong such affections 
as tuberculosis, syphilis, diabetes, uremia pure and simple, the cardiac cachexia, 
leukemia, exophthalmic goiter, cancer, etc., etc., all of which are considered 
elsewhere. (See Part III.) As a rule, they originate before conception, but 
sometimes do not manifest themselves until afterward, pregnancy appearing to 
hasten their development. In none of these conditions does delivery lead to 
any permanent improvement, and in many it rapidly hastens the end; so that 
they add somewhat to the mortality of the puerperium. Naturally sepsis is 
often present as a complication or is an actual cause of death. 

VI. Genital and Extragenital Inflammations. — The puerpera may inherit from 
the pregnant state a number of local affections of the genital tract which may 
or may not be due to her condition. Nothing would be gained by enumerating 
all these affections, but some of the more significant are as follows: Gonorrheal 
urethritis, Bartholinitis, vaginitis, cervicitis, etc., and endometritis, which may 
originate in many ways and which is discussed under diseases of the decidual. 
(Page 201.) This last condition is of enormous significance, since it is believed 
to underlie placenta prsevia and accidental separation of the placenta, and a 
great deal of premature labor, abortion, and fetal death. When delivery occurs 
with preexistent endometritis, puerperal morbidity should almost be assured; 
for it is difficult to understand how normal regeneration of the endometrium 
and the formation of a bactericidal lochia could readily occur. Perigenital: 
According to Ahlfeld, latent gonorrheal pelvic peritonitis is of not uncommon 
occurrence in pregnancy, and after delivery it may exacerbate. Chronic pelvic 
abscesses and p}'osalpinx may be present in a latent state, as may small ovarian 
or other cysts, which by undergoing rupture during labor might infect the 
peritoneum and thereby complicate the puerperium. Extragenital: If a woman 



774 PATHOLOGICAL PUERPERIUM. 

suffer during pregnancy from any pyogenic affection, such as an ulcerated tooth, 
felon, ecthymatous pustules, otorrhea, ozena, and the like, she is menaced by a 
septic puerperium. (See Part III.) During labor, a woman thus affected might 
easily transport germs from these lesions to her genitals. From another point 
of view, the act of labor has been accused of causing the generalization of a 
local infection. Thus in a latent focus of tuberculosis (caseous gland), the rup- 
ture of a small vein might be followed by general acute miliary tuberculosis. 
Finally, it has been assumed that sepsis itself may have a hematogenous origin. 
Thus, in a woman developing an extragenital suppurative focus — e. g., quinsy — 
near term, a few streptococci may reach the blood without showing patho- 
genicity; yet in passing through the puerperal uterus, they may be roused to 
activity, and a case of so-called cryptogenic sepsis may result. Extragenital 
focal affections therefore possess considerable significance for the puerperium. 

(B) MORBID CONDITIONS WHICH RESULT FROM LABOR. 

I. Shock and Extreme Fatigue from Dystocia. — Protracted and obstructed 
labors, anesthesia, operative deliveries — in a word, dystocia and all it implies — 
leave the patient in a state of shock or profound exhaustion. Extreme fatigue, 
however produced, is generally held to be a state of self -poisoning from the 
products of muscular or nervous activity; so that in these cases the woman 
may be truly said to be suffering from a toxemia due to labor. 

II. Acute Anemia from Hemorrhage. — Some hemorrhage always takes place 
in labor, so that the puerperal woman is at best anemic for a number of days ; 
but after such conditions as metrorrhagia from abortion, placental hemorrhages, 
and escape of blood post partum, the anemia becomes acute. Not only is there 
a great reduction in the red corpuscles, with its natural sequence, but the escape 
of the fluid portion of the blood must involve a great loss in the alexin or bac- 
tericidal ferment which acts as one of the principal defenses of the body. The 
symptoms, diagnosis, and treatment of anemia are discussed elsewhere. (Page 

633-) 

When we consider that to the toxemia of pregnancy may be conjoined the 
autointoxication of fatigue, and the loss of bactericidal power of the blood 
incidental to acute anemia, the morbidity and mortality of the puerperium no 
longer seem a riddle, and we can understand why a few microorganisms, even 
saprophytes, are able to produce such pathogenic effects. Indeed, it becomes 
difficult to understand how so many of these women ever escape infection and 
death. 

III. Incomplete Labor. — This term is used to denote an incomplete third 
stage, although it might be extended to include retention of the fetus or ovum. 
An imperfect third stage may be manifested in various ways ; and while due in part 
to natural shortcomings, may often be attributable to unskilful management. 
It comprises the following subdivisions: (1) Incomplete contraction and retrac- 
tion: This condition is fully considered elsewhere (page 625). In an uncon- 
tracted uterus the venous sinuses do not close naturally and thrombi form 
in situ. Thus, hemorrhage and the development of metrophlebitis, embolism, 
and air embolism are favored. (2) Incomplete evacuation: This is considered on 
page 630. A variety of tissues may remain behind after incomplete expulsion 
of the uterine contents: viz., portions of the ovum in abortion, portions of and 
even the entire placenta, fragments of membranes, and blood-clots. This dead 
tissue forms a natural breeding-place for saprophytes. Decidual fragments and 
blood are hardly to be regarded as foreign bodies and escape piecemeal in the 



MORBID CONDITIONS WHICH RESULT FROM LABOR. 775 

lochial discharge. (3) Incomplete drainage: Lochiometria. In some cases the 
normal anteflexion of the uterus becomes exaggerated to such an extent that 
there is an acute angle of flexion of the cervix and lower uterine segment which 
suffices to prevent the exit of the lochia. The uterus is large and soft and there 
are well-marked symptoms of sapremic infection. The absence of lochial dis- 
charge is of course noted. The symptoms are at once relieved by the manual 
replacement of the uterus. This is followed by a copious discharge of an ill- 
smelling fluid. As a rule, nothing is necessary, except irrigation. Much less 
commonly the cause of lochial retention is retroflexion of the puerperal uterus. 
Lochiocolpos . In rare instances the source of obstruction is in the vagina. 
This rare condition is known as "lochiocolpos." Ahlfeld reported three cases. 
In one the cause of retention was an intravaginal hematoma, and in another, 
a too thorough repair of the perineum; in the last case the patient had had a 
bad laceration of the perineum and her thighs had been tightly bound 
together. The treatment consists in the removal of the cause and in vaginal 
irrigation. 

IV. Birth Traumatisms. — These have been considered under Pathological 
Labor (Part V). They include rupture of the uterus, lacerations of the cervix, 
vagina, vulva, and perineum; also certain more remote lesions, like peroneal 
paralysis. These injuries, especially those of the cervix, are generally recognized 
as among the most important factors in puerperal morbidity. 

V. Changes in the Locality and Activity of the Bacteria of the Genital and 
Perigenital Regions Induced by the Act of Labor and Its Management. — 

1. Migration of vaginal bacteria into the uterus in protracted labors with 
faulty attitude, contracted pelves, and early escape of the liquor amnii; and also 
after normal delivery. 2. Inoculation of the genital passages with bacteria from 
without in instrumental and manual delivery. 3. Mobilization of pathogenic 
bacteria previously latent in the vaginal secretions, or associated with low forms 
of endometritis, vaginitis (ordinary pus-exciters, and gonococci). 

Bacteriology of Puerperal Morbidity. — It is generally held that the cavity 
and contents of the gravid uterus are sterile in the majority of cases. In a 
minority, a pre-existing endometritis or one contracted during gravidity, or 
death of the fetus or some maternal blood-infection , may bring about intrauterine 
infection. The claim that the vaginal secretion of the healthy woman, whether 
pregnant or not, is essentially sterile and bactericidal, appears to be untenable. 
An attempt has been made (Doderlein) to discriminate between normal and 
pathological vaginal secretions, the latter having an alkaline reaction and con- 
taining numerous formed elements; but some of the more recent authorities 
refuse to see any bacteriological significance in this distinction, claiming that 
even in normal acid vaginal mucus it is possible to detect the presence of bacteria 
which may be cultivated, the cultures being pathogenic to animals. As all are 
agreed that the external genitals swarm with bacterial life, and that the vagina 
may readily be contaminated in various ways, the only differences of opinion 
refer to the ultimate fate of the bacteria of the vagina. A few years ago the 
consensus of opinion was that they soon perished in the normal vaginal mucus, 
and that only in pathological states — vaginitis, etc. — was it advisable to practise 
antisepsis before labor. At present the pendulum appears to be moving in the 
opposite direction. This is due largely to the treatment of this subject in 
Stolz's* monograph. In two of the most pretentious of recent treatises, viz., 
von Winckel's "Handbook of Obstetrics," and Lenhartz's great monograph on 

* Studien zur Bakteriologic des Genitalkauales in der Schwangerschaft und in Wochen- 
bette Wien, 1903. 



776 



PATHOLOGICAL PUERPERIUM. 





Fig. 945. — Infection of the Vulva. 



Fig. 946. — Infection of the Vulva and 
Vagina. 





Fig. 947. — Infection of the Vagina and 
Endometrium. 



Fig. 948. — Extension of Infection 
through the tubes to the ovary. 




Fig. 949. — Extension of Infection 
through the lymphatics from the 
Uterine Cavity to the Parame- 
trium and Peritoneum. 




Fig. 950. — Extension of Infection 
through the Veins from the Uter- 
ine Cavity in Puerperal Pyemia. 



MORBID CONDITIONS WHICH RESULT FROM LABOR. 



t n 



septicemia, this reactionary view appears to be distinctly favored, and the 
findings of Kronig, Williams and others, which obtained a few years ago, to be 
correspondingly questioned. Put in its briefest compass, the idea has gained 
ground that the bacteriology of the vulva, vagina, and, in certain circumstances, 
of the uterine cavity, is one and the same, and that the same germ-content is 
common to all these divisions of the genital tract. This flora consists not only 
of the common saprophytes, but to a certain extent of the ordinary pyogenic 
cocci. The distinction between aerobic and anaerobic bacteria appears to pos- 
sess a relative importance only, for the majority of species of germs found in 
the genital tract may be cultivated by either method. So also is the distinc- 
tion between saprophytes and pathogenic germs, for virulent streptococci from 
pathological tissues do not always give positive results in animal inoculation, 
while apparently harmless streptococci, vegetating as pure saprophytes in 
healthy secretions, may be made to infect animals. The common saprophytes 
which under ordinary circumstances appear unable to attack living tissues, may 
be made to show more or less pathogenicity in animal experiments. Clinically 
we find precisely the same state of affairs. The deadly streptococcus pyogenes 
sometimes exists as a harmless saprophyte, while under certain conditions it 
may simply set up local inflammation and toxemia (Walthard), and in its 
highest form of virulence is the chief cause of septicemia. In like manner the 
common saprophytes, which, as a rule, do not infect the organism until after 
death, may not only be associated with the streptococcus and other virulent 
germs in ordinary sepsis, but in rare cases may even cause general infection 
unaided. The external genitals form a natural culture-bed for bacteria, and 
no one disputes that at least the lower portion of the vagina may be readily 
contaminated therefrom. This contamination is favored by the gaping ostium 
of the multipara, by manipulations of all kinds, by coitus, etc. If vaginitis or 
cervicitis is present, the ascent of these germs into the upper portions of the 
vagina is readily favored; and, generally speaking, it appears to be true that 
in a considerable number of vaginas, irrespective of the character of the secretion, 
the bacteria found normally at the vulva and in the lower vagina, may also 
be encountered in the upper vagina, and that under certain circumstances, 
associated with modification of the uterine secretions, the}' may enter the 
cavity of the cervix and set up a local infection. (Figs. 945 to 950.) 

To sum up briefly the normal bacteriology of the genital tract, we may state 
that the same germ-content is concerned throughout, and that while bacteria 
flourish in the external genitals of all women, they exist to a greater or less 
extent in the vaginas of a considerable proportion of women, not only in the com- 
mon functional anomalies, but in cases in which no lesion or alteration is recogniz- 
able. There appears to be no way of determining in advance whether or not the 
vagina is sterile in a given case, although it appears probable that a majority 
of vaginas may be so regarded. Thus far we have spoken chiefly of the normal 
bacterial content of the vagina, with occasional reference to the presence of 
germs due to actual disease and to the introduction of germs from without. 
These two latter possibilities now require some special attention. A woman is, 
of course, always exposed to the introduction of outside germs from manipulation 
of the genitals, from bathing in tubs, from coitus, etc.; and germs thus intro- 
duced would readily mingle with the already existing denizens of the outer 
genitals. Just before and during, labor, however, she is exposed to special 
dangers of transportation of germs from the fingers of the physician or midwife, 
and, as a rule, the germs thus introduced lodge in the vagina and become part 
of its germ-content. Even the sterile or gloved finger can play a part by trans- 



778 PATHOLOGICAL PUERPERIUM. 

porting germs from the vulva to the upper vagina. The bacteria introduced 
from without by the unsterilized finger are, as a rule, the ordinary pyogenic 
kinds, although they often possess a special virulence, particularly when trans- 
ported from diseased tissues. A very different type of transportation of germs 
occurs when, late in labor, manual or instrumental delivery of the fetus or 
placenta becomes necessary. Here traumatism is already present or is caused 
by the intervention; the hand or instrument, perhaps imperfectly sterilized, 
remains in prolonged contact with raw or abraded surfaces, and a true inocula- 
tion of virus is rendered possible. During intervention of this sort the inoculated 
germs by no means necessarily proceed from the hand or instrument, but may 
be the bacteria already present in the genital passages. 

In regard to the preexistence of pathogenic germs in and about the genitals, 
we must now consider those forms which are associated with certain local dis- 
eases. Gonorrhea is naturally the first affection to be thought of in this con- 
nection, since it may occur almost anywhere in the genital tract, and not only 
of the active, but of the dormant type. Again, in cases in which conception 
occurs in the presence of endometritis of a low grade, due either to a local in- 
fection or to the syphilitic or some other virus acting through the blood, we 
may at least infer the presence in the uterus of active or latent germs. 

Attention has already been called to the upward migration of vaginal 
bacteria in the non-pregnant, pregnant, and parturient uterus. The possi- 
bility of such a migration has been denied in years past, the claim having 
been made that the natural secretory flow was downward. In recent years 
various authorities have insisted that only upon such a theory is it possible to 
explain many phenomena; and such a supposition naturally goes hand in hand 
with that of a non-sterile vagina. If it is admitted that the upper vagina often 
contains germs even in health, which have worked their way up from the vulva, 
it is equally probable that under ordinary circumstances the germs pass from 
the upper vagina into the cervix. Since women who have not been examined 
at all, and are apparently sound, can develop severe sepsis, the disease super- 
vening even before labor is terminated, we must suppose that the vaginal germs 
have entered the uterus even during the progress of labor — or during vain at- 
tempts at expulsion. Ahlfeld believes that bacteria reach the uterus during 
labor by means of depending shreds of membrane. Within a few years it has 
been shown conclusively by Franz, Wormser, Schauenstein, and others, that 
immediately after delivery the ordinary bacteria of the vagina begin to appear 
in the lochia. Before the work of these men, the occasional discovery of bacteria 
in healthy lochia (specimens taken from the uterus itself) was thought to be due 
to some error of technique. The germs persist in the healthy lochia for a period 
of perhaps two weeks — after which the uterine cavity tends to become sterile. 
As will be seen, these microorganisms, although they include streptococcus 
pyogenes, are not necessarily to be regarded as pathogenic. The percentage of 
positive findings is from 60 to 80, this arguing a corresponding frequency of non- 
sterile vaginas. Hence their occurrence is almost physiological and closely 
corresponds to the proportion of febricula (rectal temperature of 100.4 F. 
or more) found by Bumm, who reports as high as 60 per cent, in some 
cases. These findings, with Walthard's discovery of the migration of 
vaginal germs into the non-pregnant uterus, the penetration of saprophytes into 
the uterus after death of the fetus, and especially the occurrence of intrapartum 
sepsis in protracted labors, should leave no doubt of the fact that vaginal germs 
are prone to migrate into the uterus under favorable conditions. 

One more factor should be mentioned here: viz., the possibility of the hema- 



MORBID CONDITIONS WHICH RESULT FROM LABOR. 779 

togenous origin of puerperal morbidity. Since the uterus exhibits such an ex- 
treme susceptibility to infection in the puerperium, it is possible that in some cases 
of very mild bacteriemia the bacteria may lodge in the substance of the uterus 
or other portions of the birth tract and there set up what wrongly appears to 
be a primary infection. It is enough to state that similar views have long been 
held in the case of tuberculous infection. Baumgarten even proved by animal 
experiment that tubercle bacilli which passed through the intact bladder-wall 
and caused no morbidity of the general economy determined the development 
of tuberculous lesions in the lungs. Similar arguments, backed up with cases, 
have been advanced to explain some cases of sepsis. Lenhartz has abundantly 
shown that streptococci may exist in the blood without causing fever, and may 
even set up latent endocarditis. 

Summary. — From all that has been said it is evident that, given the usual 
bacterial content of the genital passages of the pregnant woman, including any 
additions made by vaginal examination in pregnancy, by coitus, manipulation, 
tub-bathing, etc., and given, further, the possibility of the existence of latent or 
active pathogenic germs in and about the birth tract in connection with diseases 
such as local pelvic suppuration, gonorrhea, or other infectious processes ; and 
given, 'finally, the possibility of latent bacteriemia in the blood, then the act 
and conduct of labor may produce one or more or several distinct changes in 
the status of this bacterial content, viz. : 

Migration. — The ascent of vaginal bacteria into the puerperal uterus appears 
to be almost a physiological act, but must also be invoked to explain most of 
the morbidity of the puerperium; while a corresponding migration during 
arrested labor with escape of waters is likewise necessary to explain many of 
the earliest and severest types of morbidity. Other migrations of this character 
may occur early in pregnancy, causing endometritis and abortion, and may also 
be held responsible for some cases of putrefaction of the dead fetus. 

Inoculation. — In connection with severe operative extraction, manual de- 
livery of placenta and the like, direct inoculation of freshly wounded surfaces 
with germs already present in the birth-tract or adhering to imperfectly sterilized 
hands or instruments, often occurs. Under the same head belong many cases 
of criminal septic abortion. 

Mobilization. — This term may be used to denote the rousing of germ-life 
to a more active state, when the bacteria in question are present in connection 
with certain low forms of inflammation of various portions of the birth-tract 
or neighboring localities. This mobilization may produce various types of re- 
sults, and may, in some cases, cause ordinary sepsis, in others a complication 
of sepsis, while in others, again, the generalization of the morbid process may 
occur quite independently of sepsis. Any infectious process capable of existence 
in an isolated focus and in a state of dormancy might be mobilized by the act 
of labor. Bacteria which circulate in the blood in a condition of latency may 
also become mobilized and roused to activity when passing through the puerperal 
uterus. 

The bacteriology of the puerperal state is discussed more fully under the 
Etiology of Endometritis, page 785. 



(C) MORBID CONDITIONS WHICH ORIGINATE OR FIRST APPEAR 

IN THE PUERPERIUM. 

General Remarks. — As already stated these conditions had best be divided 
into focal infections, including both primitive and consecutive; and blood-states 



780 



PATHOLOGICAL PUERPERIUM. 



•<# 




>. 






.% 



.v- 



«:: 



4 < 






Fig. 951. — Putrid Endometritis in the 
Process of Healing, i, Necrotic surface 
ofdecidua; 2 , granulati on wall ; 3, decidua; 
4, muscle. — {Bumm.) 




Fig. ' 952. — Septic or Streptococcus 
Endometritis. Endometritis in 
Process of Repair. i, Necrosed 
decidtial surface with streptococci; 2, 
granulation wall; 3, muscle. — {Bumm.) 




Fig. 953. — Infection of Thrombi at Pla- 
cental Site, i, Surface of serotina; 2, 
septic thrombus; 3, granulation wall; 4, 
muscle; 5, thrombus; 6, artery. — {Bumm.) 



Fig. 954. — Septic Thrombophlebitis of 
the Uterus. i, Loosened portion of 
thrombus; 2, vein wall; 3, vein cavity; 4, 
thrombus. — {Bumm.) 



FlG - 955- — Streptococci in the Smallest Lymph-spaces between the Muscle-fibers 

of the Uterine Wall. — {Bumm.) 



MORBID CONDITIONS ORIGIN ATIXG IN THE PUERPERIUM. 781 

or general conditions, including toxaemias, bacteriemias (sepsis), pyemia, septi- 
copyemia; and anomalies of temperature, such as true fever, simple hyper- 
thermia, hypothermia, etc. This classification is essentially pathological and 
must be accompanied by some of the clinical types of morbidity. Thus 
focal infection may or may not be associated with toxaemia or bacteriemia ; of 
the blood-states, toxaemia often occurs without bacteriemia, but the latter is 
naturally associated with toxaemia, and may pursue its course with the picture 
of toxaemia. Pyaemia may occur by itself or associated with bacteriemia (sep- 
ticopyaemia). While toxaemia and bacteriemia are usually associated with 
hyperthermia, simple rise of temperature may be due to nothing more than 
mental emotion or other nervous perturbation; and in the gravest types of 
infection the temperature may be subnormal. 

PRIMARY, CONSECUTIVE, AND METASTATIC FOCAL INFECTIONS. 
Focal infections may be divided into primary and consecutive. The former 
represent a direct inoculation of the germs into an exposed surface, while the 
latter include the lesions which result from extension of the primary mischief, 
whether by continuity of surface or contiguity. In the latter case extension 
occurs by the lymphatics or the blood-vessels. When bacteria are transported by 
the blood or lymph streams to remote regions, causing metastases, we may 
speak of the latter also as consecutive lesions, although they are usually treated 
as mere subsidiary features of a general infection of the entire organism. 

Primary Focal Infections. 

These represent essentially direct inoculation of wounded surfaces, which 
may include the entire endometrium, and particularly the exposed placental 
site with its torn venous sinuses ; the lacerations of the cervix (which are never 
absent in primiparae); lacerations of the vagina, vulva, and perineum. But a 
distinction between primitive and consecutive cannot be made among these 
localities when infected, because if the endometrium is first inoculated (which is 
usually the case) the traumatisms lower down can escape secondary involvement 
only with difficulty; while the converse is equally true, since infected cervical 
tears can readily implicate the endometrium, and, generally speaking, infected 
wounds of the lower birth tract are a menace to the upper. Therefore, we 
may speak of all infections of the birth tract proper as primary. These 
lesions represent local inoculation of wounded surfaces and are essentially local- 
ized rather than diffuse. Where a great number of traumatisms occur within a 
comparatively small area — for example when the cervix or vulva tears in many 
places — the infected area may be large ; in the case of the cavum uteri, in which 
the wounded surface may even involve the entire endometrium, the infected 
area will have the same extent. An extensive perineal tear, which becomes 
infected and does not heal, will give rise to a lesion of considerable size. Natu- 
rally in any severe local infection the process will involve some of the neighboring 
sound tissue. But a diffuse vulvovaginitis, with or without endometritis, which 
is due to ordinary pyogenic cocci, although mentioned by many authorities, is 
of doubtful occurrence. On the other hand, the gonococcus, streptococcus ery- 
sipelatis and bacillus diphtherial could doubtless each set up a diffuse inflamma- 
tion of the genital canal. The primitive focal infections are thus divisible into 
(i) puerperal ulcers, (2) endometritis, and (3) diffuse inflammations of the 
birth-tract. 

I. Puerperal Ulcers. — The various birth-traumatisms of the vulva, vagina, 



782 PATHOLOGICAL PUERPERIUM. 

and cervix may, if promptly repaired, heal by immediate union; if unrepaired 
or improperly united they heal by granulation. If, however, these wounds 
become infected by the ordinary pyogenic cocci of the vaginal secretions or 
lochia, healing does not occur. If sutures have been inserted, they now cut 
through, and the lacerated surface becomes covered with a whitish-gray 
membrane, the surrounding tissues showing at times hyperemia and oedema. 
The false membrane, which bears a marked resemblance to that which char- 
acterizes diphtheria, consists of necrotic tissue in which are found an abun- 
dance of pyogenic cocci (usually the streptococcus, alone or predominating). 
The destruction of tissue which is represented by the false membrane appears 
to be due to the corrosive action of the secretion of the bacteria upon the wound- . 
surface. Despite their formidable appearance these ulcers have a natural ten- 
dency to heal, because the false membrane soon becomes separated from the 
subjacent tissues by a defensive wall of leukocytes. During the healing process 
the necrotic tissue along with its germ- content is slowly cast off, amid profuse 
suppuration, and granulation then occurs as usual. The significance of these 
puerperal ulcers is open to some doubt. In the majority of cases septic en- 
dometritis exists, so that the association of the ulcers with severe general symp- 
toms is not uncommon. In uncomplicated puerperal ulcers some authorities 
state that severe general morbidity very seldom results; while Lenhartz at- 
tributes about one-fourth the total morbidity to puerperal ulcers alone. In 
order to make the diagnosis, simple inspection should suffice, together with a 
bacteriological examination of the false membrane or the pus produced by the 
wounded surfaces. To exclude the presence of endometritis, it is necessary to 
inspect the portio vaginalis carefully with the aid of a speculum; for if the 
portio and cervical canal are normal, intrauterine infection can hardly be present. 
Conversely, if the cervix is the seat of puerperal ulcers, the endometrium, if not 
already previously involved, can hardly escape infection to some extent. A 
routine use of the speculum, however, may not be advisable; thus if a great 
amount of oedema about the vulva is present, the introduction of the speculum 
would be difficult and perhaps injurious. In such a case the patient would need 
to be treated on the supposition that the upper birth tract was actually infected. 
Treatment: Birth traumatisms should receive proper attention as soon after 
birth as possible (see Parts V and X). If puerperal ulcers have already formed 
they should be touched once or twice daily with pyrozone, carbolic acid (fol- 
lowed by alcohol), or tinct. iodine If much collateral inflammation and oedema 
coexist, lead-water will give considerable relief. In case the stitches of a rup- 
tured perineum have not cut through, they should be divided, and in any case 
taken out. So-called "pocket-ruptures" of the vaginal floor (p. 654) should be 
irrigated and packed with gauze. In regard to ulcers of the upper vagina and 
cervix, irrigation must be employed, using a glass or metal tube perforated at 
the sides. Although the endometrium is probably infected, care should be 
taken to avoid entering the uterus until the diagnosis is assured. 

Endometritis. — Puerperal endometritis comprises several varieties. In re- 
spect to cause, we have putrid, pyogenic, and mixed forms, according as the 
pathogenic microorganisms are infective, or saprophytic, or both combined. In 
respect to degree, we have simple, benign, or localized forms, in which the forma- 
tion of the leucocyte barrier and the occlusion of the placental sinuses respec- 
tively protect the contiguous structures and organism at large from the exten- 
sion of the disease; the constitutional reaction being akin to simple surgical 
fever or simple toxemia, and malignant forms, in which the microorganisms 
invade the periuterine tissues by the lymphatic route or penetrate into the 



MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 783 



uterine veins, producing in many cases such formidable complications as peri- 
tonitis and pyemia. 

II. Simple Putrid or Saprophytic Endometritis. — Introduction. — In every nor- 
mal puerperium there is a slight degree of sloughing of the endometrium in- 
cidental to regeneration of that structure. Some little time is required for the 
formation of the regenerative leucocyte layer and the lochial secretion with its 
bactericidal function. During the interval which elapses between evacuation 
and retraction of the uterus and the establishment of these defenses, sapro- 
phytes undoubtedly enter the uterus from the vagina in a large percentage of 
cases and multiply to a certain extent. These comprise not only a number of 
species of harmless "carrion-eaters," which have never been recognized as 
pathogenic, and certain forms of saprophytes which are suspected of pathogenic 
qualities under certain condi- 
tions, but also highly virulent 
germs which are capable of be- 
having as saprophytes in par- 
ticular cases, including the 
streptococcus pyogenes. We 
do not know whether these 
saprophytes should be re- 
garded as physiological sca- 
vengers or as meddlesome in- 
truders. Since the discovery 
of the existence and properties 
of intracellular ferments, we 
recognize the fact that bac- 
teria are not essential to the 
breaking up of cast-off protein 
matter. After the establish- 
ment of the lochial discharge, 
the tendency of the uterus is 
to purify itself of -germ-life. 
Bearing in mind this fact, in 
association with the treacher- 
ous character of bacteria, it 
is probably best to regard all 
germ-life in the puerperal 
uterus as something foreign 
and undesirable ; but whether 
accomplished by tissue-fer- 
ments, saprophytes or both conjoined, there is no doubt that the refuse 
proteid matter of the regenerating endometrium, in breaking up into 
simpler and more soluble and diffusible cleavage-products, is able to cause 
a very mild and transitory autointoxication, recognizable by the ther- 
mometer in a half — perhaps even more — of all puerpera. This condition, 
commonly known as "one-day fever," is described under clinical types. En- 
dometritis as such does not coexist — aside from the normal regenerative changes 
in the endometrium which hardly merit such a name. Bumm, who believes 
that in a normal puerperium the uterine cavity is sterile from first to last, 
asserts that the normal lochia are always sterile until they reach the vagina, 
when they quickly putrefy. Such a condition of affairs may frequently occur, 
but is not the rule. 





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cation) 



Fever due to Sapremia (Septic Intoxi- 
on the Seventh Day of the Puer- 
perium, Relieved by One Uterine Irrigation, 
followed by the use of ergot. 



PATHOLOGICAL PZ'IRPERIUM. 



fces multiply in proportion to the amount of dead material 

it in the it is evident That the local and general reaction must 

depend largely upon the latter factor. Even if These rezzzzs are essentially 

T - : T - : :; 7 7 : t : lerrzzizz ==::-: :: : . z zizrezazTi::: 

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sis :: 



MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 785 

varying degrees. If the uterus is evacuated within a reasonable interval, necro- 
sis of the endometrium does not result ; but if the condition is left to itself, the 
saprophytes accumulate in such numbers and activity that the endometrium, 
already in the act of throwing off dead material, becomes involved in the ne- 
crosis. If the degree of the latter is slight, we have only an intensification of 
the normal exfoliation of the mucosa; and, with cause removed, the formation 
of the leucocyte layer and the bactericidal lochia, albeit somewhat delayed, pre- 
vails in the end over the pathogenic factors. If the circumstances are less 
favorable, the degree of necrosis may be sufficient to interfere utterly with normal 
regeneration and purification of the endometrium. Mixed infection then devel- 
ops, or in certain cases the putrid endometritis may acquire such severity that 
the patient may die of intense sapremia, or even in rare cases of a generali- 
zation of the saprophytes throughout the system (gas-sepsis). The latter ter- 
mination must be of very rare occurrence, and its existence is difficult to demon- 
strate. In the majority of such cases mixed infection is present; or the 
saprophytes do not become generalized until the patient is dead or at least mori- 
bund. (Figs. 951 and 952.) 

Symptoms. — In putrid endometritis, the uterus is not properly contracted, 
and more or less tenderness is present. The lochia are very fetid, and contain 
much necrotic debris and are frothy from admixture of gas-bubbles. Pus is not 
present. An examination of the secretions shows the presence of saprophytes. 
The lochia may be "suppressed" ; this is not due to a drying up of the secreting 
surface, but to some form of mechanical obstruction — either anteflexion of the 
uterus or plugging of the os with necrotic tissue. When the obstruction is re- 
moved, there is a profuse escape of pent-up lochia having the characters already 
described. Putrid endometritis is always accompanied by sapremia which varies 
in degree with the amount of putrefaction. Pure sapremia, which is always 
due to this condition, is discussed separately on page 806. 

Diagnosis. — The various diagnostic points are included in the preceding para- 
graph. An absolute diagnosis must rest upon the bacteriology. 

Prognosis. — As long as the condition is simply a putrid endometritis, the 
prognosis depends largely upon the promptness and completeness with which 
the uterus is evacuated. But even after existing for a number of days, emptying 
of the uterus may be followed by recovery. Much also depends upon the rapidity 
of absorption of the toxins. The sapremia may be so acute that the patient's 
vital organs are quickly overwhelmed. On the other hand, the steady and pro- 
tracted absorption of toxins in an unrelieved case naturally tends to cause 
death by exhaustion. 

Treatment. — See page 790. 

III. Simple Pyogenic or Infectious Endometritis. — Definition. — A puerperal 
focal lesion due to the pathogenic action of infectious microorganisms upon the 
endometrium which is in course of regeneration. 

Etiology and Pathogeny. — The various predisposing and exciting causes of 
pyogenic endometritis have been outlined in the general sections on the mor- 
bidity of the puerperium. We do not find here the unevacuated or undrainad 
uterus which is a necessary factor in the production of the putrid and mixed 
forms of endometritis. Other factors come into play, such as the ascent into 
the uterus, during or after delivery, of infectious germs which have in some 
manner found their way into the vagina ; or the direct inoculation of the uterine 
cavity by the surgeon's instruments or hands in connection with the artificial 
termination of labor. Epidemic prevalence of the disease is a prominent fac- 
tor. In certain cases the endometrium is infected from birth wounds of the 
50 



786 



PATHOLOGICAL PUERPERIUM. 



lower genitals. It is often impossible to determine how infection takes place, 
so that we are forced to think of a preexisting endometritis or a hematogenous 
infection. Finally, predisposition plays an important part. Whatever greatly 
lowers the resisting powers of the puerpera during the early days of the puerpe- 
rium, before the establishment of the natural defenses — especially hemorrhages, 
eclampsia, preexistent toxic states, the shock of protracted labor, etc., etc., 
all render it possible for pyogenic cocci, which ordinarily would enter the uterus 
as saprophytes, to become pathogenic. In many of these cases the uterus, 
which has been completely evacuated, is nevertheless unable to contract 
properly. The placental sinuses remain patulous, or are imperfectly closed 
by thrombi; and it is this locality which is usually first attacked by the 
pyogenic cocci, many cases of simple infectious endometritis remaining local- 
ized in this area. (Figs. 953 
and 954.) 

The bacteria which cause 
this form of endometritis con- 
sist of the common pyogenic 
microorganisms, chiefly the 
streptococcus pyogenes, but 
occasionally the staphylococ- 
cus aureus and albus, and 
more rarely of other pyogenic 
bacteria. A mixture of in- 
fection is not uncommon. 

The pathogeny of infec- 
tious endometritis differs 
notably from that of the 
putrid form. In the latter, 
as already stated, the bac- 
teria do not attack the living 
tissues, and the inflammation 
is produced entirely by the 
corrosive action of the bac- 
terial secretions and decom- 
position products of the dead 
tissue. In pyogenic endome- 
tritis, on the other hand, the 
bacteria attack the living tis- 
sues, and through multiplying 
therein, produce a necrotic layer which greatly resembles the false membrane 
of true diphtheria, and which may vary greatly in thickness and extent. In 
its lightest form it has been compared to a mere "haziness," while in the 
higher degrees the necrotic endometrium may come away in large shreds. 
When dead tissue thus appears in the uterus to this extent, certain complica- 
tions may arise. Thus the os may be obstructed temporarily, and the lochia 
pent up. Again the presence of the dead tissue favors the development of an 
associated putrid endometritis. 

Symptoms; Course. — If the endometrium is attacked by pyogenic cocci during 
the period of regeneration, a struggle for the mastery ensues between the micro- 
organisms and the defensive forces. If the latter prevail, the leucocyte barrier 
increases in extent, pus is formed in increasing amounts, and through the 
mechanical action of this fluid, the necrotic tissue is broken up and washed 





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Fig. 958. — Fever due to Mild Streptococcus Infec- 
tion. 



MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 787 

away. The lochia acquires bactericidal properties, and the uterine cavity tends 
to become sterile. Under these circumstances the disease runs a benign course. 
The uterus exhibits some tenderness, and an ordinary surgical fever is present, 
caused by absorption of the toxins secreted by the bacteria. The lochia are 
purulent and entirely devoid of odor and the microscope reveals the presence 
of one or more forms of pyogenic cocci. 

If, on the other hand, the disease-germs prevail over the vital forces, malignant 
endometritis results. Two very different types of the latter are recognized and 
the two may be combined to form a third. Since infection usually begins at 
the placental site, much depends upon the condition of the latter at the time. 
If the uterus is well retracted and the sinuses closed, the defense at this point 
is effective. If the sinuses are simply plugged with aseptic thrombi, virulent 
germs may infect the latter directly, or may first penetrate between the sinuses, 
and eventually through the walls of the latter from without. This type of 
malignant endometritis which passes directly into pyemia, is manifested usually 
by a succession of chills denoting the sudden entrance into the circulation of 
a large amount of toxic material. In the other type of malignancy we may 
suppose that the placental sinuses escape, but that the endometrium is the seat 
of extensive pyogenic infection; the virulence or numbers of the germs enable 
them to penetrate the leucocyte barrier and enter the subjacent lymph-spaces 
in such numbers and activity as to infect the parametrium or perimetrium or 
even the blood itself. Clinically this type of endometritis would be expressed 
by evidences of pelvic inflammation superadded to uterine pain and tenderness. 
As is readily apparent from what has been said, the moment an endometritis 
is to be classed as malignant, the infection has already extended beyond the 
uterus — either along the uterine veins or into the pelvis. These two types of 
malignant endometritis, viz., the venous and lymphatic, may be conjoined, and 
we then have a special blood-state termed septicopyemia (q. v.). 

Diagnosis. — In the milder forms of pyogenic endometritis there may be but 
little constitutional disturbance — nothing beyond a slight resorption-fever — and 
local symptoms may likewise be absent. Under such circumstances diagnosis 
can be made only by the purulence of the lochia, and the presence therein of 
the pyogenic cocci in large quantities. In higher degrees we find tenderness 
and the toxemic state more highly developed, this accentuation, as in other 
suppurating cavities, being sometimes dependent upon imperfect drainage. The 
evidences of malignancy have already been enumerated. Since streptococci 
have been known to enter the circulation and remain therein in a latent state 
for days, we should examine the blood in all cases of persistent elevation of 
temperature, even in the absence of symptoms of blood infection, or extension 
of the morbid process beyond the uterus. 

Prognosis. — As long as the uterus is movable, drainage maintained, blood 
examinations negative, and the march of the temperature in accord with simple 
localized suppuration, the prognosis is good, the condition hardly calling for 
active treatment. As soon as there is evidence of extension of the process by 
the veins or lymphatics, the question is no longer one of endometritis, for the 
latter, per se, could hardly endanger life. In those extreme cases in which the 
entire uterus is inflamed and softened, extension of the disease has already 
occurred, death really taking place from pyemia or peritonitis. 

Treatment. — See page 790. 

IV. Endometritis from Mixed Infection ; Composite Endometritis. — While this 
affection is of frequent occurrence and is naturally grave in character, its charac- 



7S8 



PATHOLOGICAL PUERPERIUM. 



teristics have been so thoroughly discussed under ^the individual types of en- 
dometritis that but little more need be given here than a recapitulation. 

Whenever an unevacuated uterus leads to the development of putrid endome- 
tritis, a pyogenic infection is readily grafted upon the initial trouble. If strepto- 



mLumbarlert _— 




Suspens&yLjml.ar(7i>ary 
OitarianLymi 

RwtdOwy 

fundus ulen - 
HjtuTube. 
ffiy/UftounaLyamenl 
AtitiesiomorGieswianSecSair 



Fig. 959. — Puerperal Uterus, Three Hours Post Partum, the Site of Streptococcus 

Endometritis. — (Sellheim.) 

cocci are present at the outset, as "acting saprophytes," they may be roused 
to the virulent or infectious state through rapid multiplication in the presence 
of the necrotic tissue. From another point of view the presence of a putrid 
endometritis causes a lowering of the local resisting power, an impairment of 



PlaosntalJite 
Bladder 

tfreffim | 
^mt. Cervical Lip. N^ 
Mroitus Vaginae 

EXtQs. 



Perineum 



J??.6bm.7l.Art. 
Post.Cerv.lip. 




Jnus 
7nt. Sp/uncter 
£xt.SphincterAni. 



Fig. 960. — Sagittal Section of a Puerperal Uterus Three Hours Post Partum with. 
Streptococcus Endometritis. Same case as Fig. 959. — {Sellheim?) 



the regenerative faculty of the endometrium, and a depreciation of the bacteri- 
cidal power of the lochia. Under these circumstances streptococci, however 
introduced into the uterus, are able to flourish and exert their pernicious 
influence. 



MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 789 

We have already seen that putrid endometritis need not always be the 
primary lesion; for the diphtheroid membrane which results from pyogenic 
infection of the endometrium constitutes necrotic tissue upon which saprophytes 
are able to feed and increase in numbers. According to Bumm, the pyogenic 
cocci usually take precedence in associate infection; they cause necrosis of the 
endometrium, and thereby enable the saprophytes to obtain a foothold. Gener- 
ally speaking, the conditions are such that the development of mixed endometritis 
is naturally favored. Pure examples of saprophytic or pyogenic infection are 
doubtless less frequent than is usually taught. 




Fig. 961. — Lochial Secre- 
tion of Putrid Endome- 
tritis. — (Bumm.) 



Fig. 962. — Lochial Secre- 
tion of Septic Endome- 
tritis. — (Bumm.) 



Fig. 963. — Lochial Secre- 
tion of Gonorrheal En- 
dometritis. — (Bumm.) 



Symptoms; Course. — In the majority of cases composite endometritis doubt- 
less begins with the putrid form; i. e., with an unevacuated uterus. If the 
latter is emptied, the expected defervescence does not occur, and it becomes 
apparent that the composite endometritis has been transformed into the simple 
pyogenic form. The prognosis of the latter is, however, much graver than is 
the case when the pyogenic affection is primary ; and it is very evident that the 
associate affection has so crippled the defenses of the organism that the endome- 
tritis is very likely to become malignant. 

As already implied, unless the putrid endometritis is of such intensity or 




Fig. 964. — Glass Cannula for Obtaining Lochial Secretion from the Uterus. 

(£ natural size.) 



duration as to necrotize the endometrium, thorough evacuation of the uterus will 
transform the composite into the simple pyogenic form — since the saprophytes 
are thereby deprived of nutriment. Under unusual circumstances, such as 
retention of a large amount of fetal tissue for a protracted period, or pressure- 
gangrene of the uterus, the putrefaction of the latter is so extensive that removal 
or disinfection of the necrotic tissue is impossible. If after repeated douching 
of the uterus the lochia continue fetid, it is evidence that the endometrium has 
been extensively involved in the putrefactive process. Such cases naturally 
remain composite to the end, and are comparable with neglected cases in which, 



790 PATHOLOGICAL PUERPEPJUM. 

for one reason or another, there has been no attempt to evacuate the 
uterus. 

When under such circumstances the affection remains composite to the end, 
the condition known as sapremic sepsis develops: or, in other words, the blood 
changes which tend to accompany each disease singly, are found side by side. 
Moreover, in the very highest type of puerperal morbidity, the saprophytes 
may enter the circulation before death and cause the so-called gas-sepsis (,?. v. . 
Uncomplicated sapremia (from putrid endometritis) and uncomplicated sepsis 
are without doubt responsible for many deaths among puerperae ; yet it is very 
likelv that in untreated cases mixture of infection results sooner or later. 

Diagnosis. — The lochia afford the sole means for a rational diagnosis. If 
this discharge is both fetid and purulent, containing in addition gas-but": les; 
and if a microscopic examination reveals both saprophytes and pyogenic cocci 
in large numbers, the diagnosis is assured. 

Prognosis. — If defervescence occurs within a reasonable period after the 
uterus has been emptied and irrigated, the prognosis is good. If the fever does 
not disappear, or if it returns after a short fever-free interval, it is probable 
that the streptococci have passed beyond the confines of the endometrium. 

Local Treatment of Endometritis. — For various reasons, and especially because 
nearly every case of endometritis may be regarded as containing the possibilities 
of a mixed infection, it is better to consider the treatment of all the forms of en- 
dometritis under a single head. The best authorities are now inclined to conserv- 
atism as regards the local treatment of puerperal endometritis, the weight of 
evidence tending to the conclusion that active intrauterine treatment indiscrimi- 
nately applied, in the presence of streptococcic endometritis, as proved by a bac- 
teriological examination of the uterine secretion, does much more harm than good, 
and my experience has led me to coincide with this conclusion. I hold the opinion 
that it is neither necessary nor advisable to invade the uterine cavity in even' 
mild case of endometritis; such cases are best treated by rest in bed, the applica- 
tion of an ice-bag over the uterus, the administration of ergot and vaginal 
irrigations, the last only when the lochia are foul. The local application of 
cold tends to promote uterine contraction and perhaps helps to inhibit the 
growth of bacteria, while the administration of ergot, as elsewhere noted, aids 
in promoting contraction and in furthering the processes of involution by 
closing the lymphatics of the uterine wall. Vaginal irrigation, if carefully 
given (Part X), is harmless and probably beneficial. A 2 or 3 per cent, solution 
of carbolic acid, or 0.5 or 1 per cent, solution of lysol, or a 25 to 50 per cent, 
solution of hydrogen peroxide may be injected every four to six hours. When, 
however, the symptoms are of a more severe type, especially if they begin 
to appear soon after labor, in all cases in which placental retention exists or 
is strongly suspected, the interior of the uterus should be digitally examined 
(Part X). If placental or other debris, such as clots or pieces of membrane, 
is found, it should be digitally removed and the uterus irrigated (Part X). 
The digital examination of the puerperal uterus, the removal of the placenta, 
and the method of giving the intrauterine douche are described in connection 
with obstetric operations (Part X). The mere retention of membranes in the 
absence of symptoms of infection is not a justification for invading the uterine 
cavity after deliver}-, nor should any violence be done to the uterine wall in 
the effort to remove them, even if symptoms are present. In either case the 
remedy is more dangerous than the condition. On the other hand, if the interior 
of the uterus is smooth it may be irrigated, but further manual or instrumental 
interference can do nothing but harm. It is possible that these injections act 



MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 791 

simply by emptying the uterus of septic contents, and that sterile water would 
serve as well as disinfectant solutions. Of the latter, perhaps a 50 per cent, 
solution of alcohol is well worth trial, as much as one and a half to two quarts 
being used. If no benefit is observed, the injection may be repeated in twelve 
hours; but if improvement does not follow the second injection, little benefit 
is likely to be derived from further intrauterine treatment. Should the in- 
jections appear to cause improvement, they may be cautiously repeated from 
time to time, according to results. Should no benefit be observed, it is unwise 
to continue them, as they are by no means free from danger. A careful bimanual 





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Fig. 965. — Fever due to Suppurative Mastitis. Two abscesses in one breast incised 
and drained. Temperature on the twenty-seventh day of the puerperium normal and 
pulse seventy-four. 



examination should be made in each case, and in those cases in which the para- 
metrium is involved, intrauterine injections should not be given, but vaginal 
injections may be employed. Antiseptics may be introduced into the uterine 
cavity in the form of suppositories or on gauze. The use of the iodoform pencil 
is strongly advised by some, while others advocate the use of iodoform gauze. 
I have abandoned the use of both. Carossa fills the uterus with gauze which 
he saturates at hourly intervals with 25 to 50 per cent, alcohol. Among other 
substances which may be introduced by the tampon are chlorine water, tincture 
of iodine, and especially the colloidal silver of Crede (see page 818). In the 
past the curette has played an important part in the treatment of puerperal 



792 PATHOLOGICAL PUERPERIUM. 

endometritis, but the best authorities have now reached the conclusion that 
its use, while often productive of the greatest good in the treatment of sepsis 
following abortion, does far more harm than good in the treatment of sepsis 
at full term. The objections to its use may be stated as follows: (i) It is 
difficult to go thoroughly over the whole surface of the uterus; (2) the puerperal 
septic uterus is soft and easily perforated; this accident has happened to expe- 
rienced operators; (3) whatever is necessary can usually be done more intelli- 
gently and thoroughly by the finger; (4) last and most important, curetting 
destroys the barrier which nature has established against the progress of infec- 
tion, and which has been discussed in connection with the pathology of puerperal 
septic endometritis (page 783, Fig. 956). Moreover, experience has shown that 
good results have been obtained by methods similar to those which I have 
described. Kronig obtained, by expectant and supporting measures, a mor- 
tality of 4 per cent., and in all his cases the presence of the streptococcus was 
demonstrated in the lochia. It is doubtless true that in certain cases of 
fever following delivery there is prompt subsidence of symptoms after curet- 
tage. Such cases, however, are cases of sapremia which almost always termi- 
nate favorably, either spontaneously or under treatment. If streptococci as 
well as saprophytes happen to be present, curettage may result in the exten- 
sion of the infectious process and in serious and even fatal accidents. 

Resume. — To sum up the treatment of puerperal endometritis: (1) retained 
placenta should, when possible, be removed digitally; (2) mild cases should be 
treated expectantly by the use of the ice-bag, ergot, etc., vaginal douches being 
used if the lochia are offensive; (3) in severe cases the uterine interior should 
be carefully examined digitally, and when practicable, bacteriologically ; debris 
should be manually or instrument ally removed; the uterus carefully irrigated 
and the irrigation repeated if necessary within twelve hours, preferably with a 
50 per cent, solution of alcohol. This treatment to be commenced as early 
as possible. If intrauterine treatment is not beneficial, it should be discontinued 
and every precaution taken to prevent injury to the soft parts of the mother 
during manipulations. 

V. Mastitis. — (See Diseases of the Breast, Part VII.) 

Primary focal lesions in the genital canal which result from specific infectious 
processes, as gonorrhea, diphtheria, and erysipelas, receive separate attention 
on page 804. 

I have already insisted that malignant puerperal endometritis implies some 
form of secondary extension of the primary mischief; in other words, it is not 
merely the going from bad to worse of the uterine lesion. I shall first enumerate 
the results of extension by continuity of surface, which are relatively benign in 
comparison with the conditions which result from extension along the vessels. 
From puerperal ulceration near the urethra, the urinary tract may become in- 
volved ; from ulceration of a complete perineal tear, the rectum may be involved, 
at least in theory. Finally, in pyogenic endometritis the tubes are readily 
involved by continuity. These conditions are now briefly described. 

Consecutive Focal Infection. 
Consecutive Lesions from Extension by Continuity. 

VI. Puerperal Infection of the Urinary Tract (Pyogenic Urethritis, Cystitis, 
Pyelitis, Pyelonephritis). — Naturally these conditions do not differ materially 
from ordinary urinary infection from the use of septic catheters. Indeed, this 



MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 793 



very accident may occur in the puerperium, and hence catheterization is to be 
avoided as far as possible and done only under the strictest asepsis (see Manage- 
ment of Puerperium). If infection has already occurred as shown by the onset 
of cystitis, the bladder should be washed out every four hours with a weak solution 
of boric acid. This is best done by means of a silver return catheter and fountain 
syringe, the bladder having been emptied. The reservoir should have but a 
slight elevation above the bladder. No air should be admitted. As soon as the 
patient feels the sense of fulness in her bladder, she should be allowed to empty 
it. Urotropin should be given inwardly. If the upper part of the urinary 
tract becomes infected, the 
resulting case is one for 
operative surgery. Puerperal 
gonorrheic urethritis is men- 
tioned elsewhere. (Fig. 966.) 

VII. Puerperal Proctitis. — 
This condition, which is ex- 
tremely rare, and might also 
occur from some accident, as 
from a septic syringe, repre- 
sents an inoculation of some 
raw surface, and is in fact a 
puerperal ulcer of the rectum, 
having the same symptoms, 
diagnosis, and treatment. 
Puerperal rectal gonorrhea 
may occur. 

VIII. Puerperal Salpingitis. 
— This is stated to be a some- 
what infrequent consecutive 
lesion and must be distin- 
guished from salpingitis which 
occurs secondarily to perito- 
nitis. Uncomplicated salpin- 
gitis from direct extension of 
pyogenic endometritis has the 
characters of abscess-forma- 
tion, supervening with a rigor, 
a fever which may reach 104 , 
and in some cases severe pain. 
Physical examination will re-- 
veal a tumor which when de- 
veloped is of a sausage shape. 

The treatment is that for localized suppuration elsewhere. If the diagnosis is 
made early an ice-bag may be applied. After pus has collected it must be 
evacuated, it being understood that the primary focus in the uterus has been 
properly treated. The conservative vaginal incision should be employed to 
reach the pus. Gonorrheal puerperal salpingitis will be mentioned elsewhere; 
likewise salpingitis secondary to septic peritonitis. 





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Fig. 966. — Fever due to Gonorrheal Cystitis in 
the Puerperium, the Gonococcus being found 
in the Pus from the Urethra. Irrigation of 
the bladder practised and urotropin administered. 



794 PATHOLOGICAL PUERPERIUM. 

Consecutive Lesions Due to Extension Along the Uterine Vessels. 

We know that even in relatively mild cases of endometritis, streptococci are 
able to break through the leucocyte barrier into the uterine lymph spaces, 
although they do not necessarily set up metritis or other consecutive lesions. 
Generally speaking, whenever the pyogenic cocci pass this barrier, we should 
no longer speak of endometritis, for with these germs once in the lymph spaces 
there is nothing to prevent the further extension of infection which may involve 
the uterus, parametrium, perimetrium, or ovary; in fact all the accidents of 
extension result here save those which arise from direct extension along the 
veins at the placental site. We therefore differentiate between lymphatic and 
venous septicemia, the latter being known as pyemia. 

Consecutive Lesions from Lymphatic Extension. 

These comprise metritis, pelvic lymphangitis, parametritis, oophoritis, peri- 
metritis (or benign peritonitis), and malignant or general peritonitis. The par- 
ticipation of the peritoneum may be secondary to metritis or parametritis. 
With any of the accidents we see always the occurrence of toxemia with or 
without bacteriemia. It should be stated, also, that a low form of peritonitis 
may follow simple putrid endometritis and also gonorrhea. On the other hand, 
sepsis may be so sudden and intense in development that dissolution of the 
blood may outstrip the formation of consecutive foci. Under such circumstances 
there would probably be found at autopsy some such coincidence as antepartum 
sepsis, with pressure-gangrene of some part of the uterus and evidences of 
beginning peritonitis. From the blood and some of the viscera we may obtain 
pyogenic cocci in association with putrefactive bacteria. 

The consecutive lesions enumerated above will now be discussed individually. 

IX. Metritis. — This term is practically synonymous with malignant endome- 
tritis. As the endometrium and muscularis are continuous the latter is invariably 
infected whenever the leucocyte barrier does not withstand the attacks of the 
infecting organisms. The streptococci usually multiply along the coarser 
lymphatics of the uterus, and may not pass through the vascular walls. In this 
case the parametrium may be the first structure to feel the brunt of the attack 
or the peritoneum may be selected. In other cases the streptococci multiply 
throughout the finer lymphatics as well, and also pass through the vascular 
walls, setting up intramuscular abscesses, and sometimes lead to necrosis of 
entire portions of the musculature (metritis dissecans). This so-called lymphatic 
infection of the uterus is probably less common than the direct infection of 
the veins at the placental site. The latter is the first and commonest seat of 
puerperal endometritis, and Lenhartz states that at least one-half of all puerpera 
who come to the autopsy-table show some evidence of thrombophlebitis. The 
streptococci may not only enter the lumen of the veins, but may also proceed 
along their outer walls and eventually penetrate them. As soon as the thrombi 
once become infected, it is no longer a question of metritis, for the disease is 
propagated along one or more of the uterine veins, and we have special con- 
secutive lesions. 

We must reiterate that puerperal metritis is not a clinical entity. The 
moment the leucocyte barrier is overcome, or the thrombi in the uterine sinuses 
are attacked, the infection is already to be considered as having extended beyond 
the uterus. This is best shown clinically by the fact that no indications for 
hysterectomy for puerperal sepsis can be laid down save in exceptional cases 



MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 795 

like an adherent placenta, an infected myoma, etc., in which the operation is 
really prophylactic. 

Consecutive lesions beyond the limits of the uterus must now be considered. 
As already-stated, these are divisible into (i) lesions due to lymphatic extension — 
parametritis, ovaritis, perimetritis (or benign peritonitis), and general or malig- 
nant peritonitis — and (2) lesions due to venous extension, which comprise the 
various types of puerperal phlebitis. 

X. Parametritis. — This lesion is caused by propagation of the streptococci 
from the lymph spaces of the muscularis of an infected uterus and also from 
extensive cervical puerperal ulcers which extend directly into the parametrium. 
In the former case the germs are propagated along the pelvic lymphatics where 
they set up a lymphangitis ; while in the latter case cellulitis is the immediate 



•0%>a^ 




v 




# 7 



Fig. 967. — Uterus and Adnexa from a Case of Acute Streptococcus Infection and 
Septicaemia Lymphatica. Death on twelfth day after Caesarean section. No peri- 
tonitis and no pus in the tubes; macroscopic appearance of endometrium normal. — 
(Author's case at the New York Maternity.*) 



result. In the absence of natural barriers the loose tissue of the pelvis is quickly 
infected. The parametrium of one or both sides becomes the seat of hyperemia 
and serous infiltration. The diseased foci, usually miliary, are then invested by 
a wall of leucocytes which limits the further extension of the process. Abscess- 
formation occurs whenever the miliary foci coalesce, but the natural leucocyte 
defense is generally so vigorous that the streptococci are vanquished at an early 
stage before coalescence occurs. In this termination the exudation is gradually 
absorbed. When abscess-formation occurs the pus tends to gravitate into the 
perirectal and retroperitoneal connective-tissue. The abscess may penetrate 
into the rectum or vagina or may point externally at the groin above Poupart's 
ligament. (Figs. 970 and 971.) 

Parametritis may, of course, be but a single feature in a complicated septic 
process, in association with endometritis and other local lesions and septicemia; 
but when parametritis is the principal lesion, it simply gives rise to the same 
* See "Trans. N. Y. Obstetrical Society," April 16, 1895. 



796 



PATHOLOGICAL PUERPERIUM. 



constitutional reaction as does any other large acute abscess, and it would 
hardly be proper to rank such a condition as puerperal sepsis. Thus, invasion 
of the parametrium is heralded by a chill and a sharp rise of temperature, and 
a typical suppuration-fever follows. If the leucocyte defense succeeds in keeping 
the minute initial abscesses from coalescing, the process is aborted in about 
ten days or two weeks and defervescence results; but if the streptococcus pre- 
vails, the gradual formation of the abscess is marked by the usual temperature 
curve of an abscess fever. High evening temperatures are succeeded by profuse 
sweats and morning remissions. Relief by natural or surgical evacuation is 
followed by defervescence. Clinically the rigor and rise of temperature are 
associated with pain and tenderness in situ and in some cases pressure-pain is 
also referred to the lower extremities or loins. Bimanual examination reveals 
the presence of a mass at one side of the uterus (exceptionally at both sides) ; 
several days, however, being required for the development of the exudate. The 
mass at the side of the uterus tends to increase in size, and the sensitiveness 
to manipulation increases, especially in cases in which the peritoneum becomes 




VAGINA 
RECTUM 

Fig. 968. — Parametric Inflammation 
in the Cellular Tissue of the 
Right Broad Ligament Pushing 
the Uterus to the Left. — {Dakin.) 



VAGINA 



Fig. 969. — Parametric Inflammation of 
the Cellular Tissue of the Right 
Iliac Fossa, and Slight Induration in 
the Right Broad Ligament. The Uterus 
is in the Normal Position. — (Dakin.) 



involved secondarily. The respective terminations in resolution and suppura- 
tion have already been noted. In either case more or less of the infiltration 
may persist as organized connective tissue, and incidentally the uterus may 
become displaced in any one of several fashions. 

The diagnosis of parametritis is naturally considered with that of perimetritis, 
for the two conditions not only present much in common, but very often coexist. 

Treatment. — The management of a parametritis, whether essential or a com- 
plication, is that of an impending or actual abscess-formation in general. At the 
outset an ice-bag is applied and opiates given, both rendering especial service 
in warding off suppuration and peritonitis. The patient must also be kept 
immobilized to the greatest possible extent. This management, when put in 
force at an early period, justifies a good prognosis. If suppuration is under 
way warm compresses about the abdomen may hasten it. Pus should be 
evacuated by the posterior vaginal incision. In order to hasten resolution, both 
in abortive cases and after suppuration, the patient should be placed on her 
back with elevated hips, and the posterior cul-de-sac irrigated twice daily with 
several quarts of hot water. 



MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 797 

Oophoritis may be regarded practically as a parametritis ; it is caused usually 
by lymphatic extension from the endometrium. 

XI. Peritonitis. — Benign Forms Of. — Under this head belong various types 
of circumscribed peritonitis which comprise perimetritis, perisalpingitis, peri- 
oophoritis, etc., and which are due to a simple extension of inflammation from 
the uterus, parametrium, tubes, ovaries, etc. The peritoneum may also be 
involved as a result of rupture of the uterus, of a parametritic abscess, and of 
emigration of bacteria (practically only the gonococcus) from the tube into the 
peritoneal cavity. Unless the bacteria which come in contact with the peri- 
toneum possess a high degree of virulence, the inflammation remains circum- 
scribed, chiefly because the exudation brings about adhesion of the parietal and 



Degenerated Iliopsoas Muscle 
Abscess Cavtty 
Crural Artery 

Crural Vein 



Iliopsoas Muscle 
Crural Vein 




Degenerated 1 

Int Oblique 
Muscle 



Rl. Ureter 
Ant.Lip cfCervioc 



Left round 
Ligament 



Subperitoneal 
Pus 



Left l/reter 



raruvcuji 
Inflam-m* 



nticn 



Pelvic Floor 



Pelvic Floor 
Left Vag Wall 



Fig. 970. — Transverse Section of the Pelvis from a Primipara Four and a Half 
Months Post Partum, showing Parametritis and the Formation of Puerperal 
Pelvic Abscesses. — (Sellheim.) 



visceral peritoneum with resulting encapsulation of germs. The systemic reac- 
tion in these cases is that of localized peritonitis rather than what is comprised 
under puerperal infection. In regard to the genesis of peritonitis in the puer- 
perium, the lymphatics are in most cases the organs at fault; the bacteria 
passing from the lymph spaces of the uterus directly into the peritoneal cavity. 
Thus perimetritis becomes much the more common localization. The other 
local types already mentioned occur with greater infrequency, by reason of their 
special etiology. It may be stated that a severe parametritis almost necessarily 
extends to the peritoneum, and that the same is true of acute salpingitis, acute 
oophoritis, etc. When peritonitis results from rupture of the uterus, or from an 
acute abscess, etc., its character must depend wholly upon the relative virulence 
or sterility of the escaping substances, and the same is true of the escape of 



798 PATHOLOGICAL PUERPERIUM. 

pusfrom the tubes into the peritoneal cavity. In all such cases the perimetrium 
is necessarily attacked. Hence for practical purposes benign peritonitis is vir- 
tually equivalent to perimetritis. (Fig. 972.) 

Perimetritis. — This condition, like endometritis and parametritis, possesses 
a distinct clinical individuality, and occurring as the chief clinical feature of a 
morbid puerperium may run its course as a local infection with its natural 
systemic reaction. The most important thing to know about perimetritis is 
that it occurs chiefly from propagation of bacteria through the lymph spaces 
of the muscularis of the uterus, without the necessary production of a high 
degree of metritis. When the streptococci enter these lymph spaces, it is only 
when of the highest virulence that they occupy the finer radicles and from these 
attack the muscular substance. Under ordinary circumstances they simply 
travel along the coarse spaces until the peritoneum is reached; so that peri- 



Sacro- iliac Articulation .jj^^\ 



Pararectal extraperitoneal pus cavity 

! , Ischial nerve 

K/ Superior gluteal Art. 



C/reter 

Thrombus ^Hypogastric Vein- 
Intraperitoneal pus cavity 

2%~,r Uterine Art, 
**^ — Thrombus 



Otvitytf Uterus with ~blood-clot 
Pus in utew-ves.pouch 



Bladder 



M HS 



Fig. 971. — Horizontal Section of a Pelvis from a Primipara Three Weeks Post 
Partum, showing Abscess Cavities in Utero-vesical Pouch, in Douglas's Cul- 
de-sac, and also Pararectal and Extraperitoneal Suppuration. — {Sellheim.) 

metritis is much more likely to result than severe metritis. Through this pecu- 
liarity we are able to understand why bacteria of low virulence, such as the 
gonococcus and even saprophytes (as Ahlfeld implies), may in some cases reach 
the peritoneum and set up a low grade of perimetritis. Ahlfeld believes that 
the puerperium often rouses to activity a preexistent slight localized perimetritis, 
especially in latent gonorrhea. 

The course of benign peritonitis has already been stated. The exudate which 
is shut off by adhesions may be either serofibrinous or purulent. Of great 
interest is the frequent occurrence in pus of this source of the bacillus coli, 
which is believed to pass through the intestinal wall after adhesions have formed. 
When pus forms in connection with perimetritis, the almost invariable result is 
intestinal perforation. 

While perimetritis may occur as part of a general septic process, or in asso- 



MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 799 

ciation with parametritis, it may also in certain cases constitute the principal 
feature of the puerperal morbidity, especially in the cases described by Ahlfeld 
in which an old perimetritis is roused to activity by labor. Under such circum- 
stances we should expect to see the symptoms of an ordinary peritoneal reaction, 
including great pain and tenderness, small, rapid, and incompressible pulse, rapid 
breathing, thirst, and vomiting. The patient lies in the dorsal position with 
knees drawn up to diminish abdominal tension. Perimetritis is ushered in by 
a chill and a sharp rise of temperature, which continues moderately high 
and without morning remissions while somewhat higher at night. When pus 
forms, a second chill and renewed ascent of temperature occur. After perime- 
tritis has lasted for several days the presence of the exudate may be made out in 
Douglas' cul-de-sac, or in some cases in the entire lesser pelvis. This having 
become encapsulated, the uterus is immobilized. If suppuration does not occur, 
this exudate may be absorbed after several weeks; but with the formation of 
pus, softening and fluctuation become apparent, and the abscess, as already 
stated, may be expected to rupture into the intestine, or exceptionally into the 
vagina, or externally, or even through the limiting wall into the general peri- 
toneal cavity. The diagnosis of perimetritis should not be difficult, since the 
phenomena of the peritoneal reaction are so characteristic. The chief point of 
interest lies in distinguishing at the outset between perimetritis and parametritis ; 
since both affections begin at about the third or fourth puerperal day with a chill 
and sharp rise of temperature, and are attended with pain, tenderness, and the 
formation of plastic material. The peritoneal reaction should be sufficient for 
discrimination. It frequently happens that the two affections coexist, and in 
this case the symptoms of parametritis are naturally masked, and a bimanual 
examination becomes indicated, which, owing to the great pain and tenderness 
resulting, can with difficulty be carried out. Treatment: Perimetritis and para- 
metritis require precisely the same management, viz., absolute rest, the ice-bag, 
and opiates; so that a differential diagnosis during the early days is not a 
matter of supreme importance. Rest must be so absolute that no attempts at 
irrigating the birth tract are permissible, even if the lochia are foul and purulent. 
The surgical treatment is along the lines of parametritis and will be discussed 
more fully in the general section. 

General or Malignant Peritonitis. — Bacteria of comparatively low virulence 
bring about benign peritonitis or perimetritis; and under precisely the same 
circumstances, highly virulent germs cause a general peritonitis. According to 
the general teaching the latter affection follows most commonly upon an en- 
dometritis set up by highly infectious germs; Lenhartz, however, has shown 
the great relative frequency with which severe parametritis can bring about 
malignant peritonitis. But this affection is not due necessarily to lymphatic 
extension, since it may result from direct inoculation of the peritoneum by the 
contents of a ruptured uterus or a preexisting abscess. It has been commonly 
taught that malignant peritonitis is usually a complication or feature of severe 
general sepsis, both being the natural consequence of highly virulent strepto- 
cocci ; but many case-histories seem to show that the general condition in malig- 
nant peritonitis is not septic infection of the blood, but profound toxemia caused 
by the rapid multiplication of germs over the entire peritoneal surface. In 
other words, malignant peritonitis may often represent a purely local infection, 
limited only by the great extent of the peritoneum. 

Malignant peritonitis is undoubtedly due to the high virulence of bacteria 
which spread over the peritoneal surface without any attempt at the formation 
of isolating adhesions. It does not appear that the germs are necessarily of 



800 



PATHOLOGICAL PUERPERIUM. 



Peritoneum covered 
with fibrin and 
pus. 



^'^m&'m 




Unaffected muscle. 



^ Portion of muscle 
j omitted. 



m 



>.<&». 



\ Moderate exuda- 
/ tive endometritis. 



Fig. 972. — Section through the Wall of a Uterus showing Streptococcus Endo- 
metritis, and Extension of the Infection through the Lymphatics to the Peri- 
toneum, Causing Peritonitis. Death on the thirteenth day post partum, after a 
full-term, delivery, from general purulent peritonitis and exhaustion. Patient was 
at first treated on the basis of a diagnosis of acute malarial infection. No local treat- 
ment was at anytime used. X 75. — (From a specimen in the Pathological Laboratory 
of Cornell University Medical College.) 



MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 801 

unusual virulence before gaining the peritoneum, but may find conditions there 
which favor their rapid multiplication. 

Case-histories show that a woman may be fatally septic and yet have only a 
localized peritonitis; while as already stated, complete purulent peritonitis may 
not be accompanied by general sepsis. (Fig. 972.) There is much evidence to> 
show that lymphogenic malignant peritonitis is a phase of puerperal morbidity 
which is sui generis, bearing no definite relationship to perimetritis, endometritis,, 
or septic infection of the blood. It is preeminently a streptococcus disease. The 
symptoms are those of general peritonitis from other causes. The most striking 
symptom is the extreme degree of meteorism which results from intestinal 
paresis, and which produces compression of the thorax and dyspnea. The 
prodigious amount of toxins produced and absorbed tends to overwhelm the 
heart, and the pulse-rate rapidly mounts to the neighborhood of 150. Ahlfeld 
regards malignant peritonitis as essentially a disease of the very early puerperium 
— most frequently of the 

first day. The chill is i#K^9NE^fiflte 

often wanting, and the *& 

rapid supervention of 

great agony referred to ..- * 

the bowels; vomiting, ^ .* 

restlessness, and anxiety • _. *• ' - ' 

suggest that the patient ^7 v V' 

has swallowed an irri- "".--: 

tant poison. Lenhartz, * _,~ 

however, described an 

entirely different course, . fc r- ■:■■ 

in which the puerperium & 

begins favorably, then 

parametritis develops, * C- 

and eventually general v ""'. WB 

peritonitis; the evolu- ;*& 

tion of the disease being 

much less fulminant. "^ ^^ 

He found the symp- 
toms to occur in the fol- 

1 • 1 1 .-|i / ■, Fig. 973. — Small Blood-vessel from the Endometrium - 

lowing order: emu (ai- OF FlG ^ 2 ^ SHOW ing Streptococci among the Blood* 

ways present) ; vomit- and Endothelial Cells. X 700. 

ing; abdominal pain; 

diarrhea. These were succeeded by great weakness and meteorism. All 
authors speak of the euphoria and mental clearness which are sometimes pre- 
sented by women who are already nearly pulseless. They no longer feel pain 
nor distress. As the symptomatology of this condition agrees with that of acute 
general peritonitis from other causes, further details may be omitted. 

The diagnosis should be self-evident and the prognosis is all but hopeless. 
Since occasional recoveries occur, the selection of favorable cases becomes of 
great importance. As the bacteria spread over the peritoneum and proliferate^ 
with production of toxins, a serofibrinous exudate appears which tends to- 
become purulent. In the absence of general sepsis, there is an opportunity of 
accomplishing something by treatment directed to the peritoneum. In the very 
earliest stages an attempt should be made to limit the process by ice and opiates. 
After meteorism has fully developed it is of course useless to expect anything; 
from abortive treatment. In theory, prompt laparotomy with evacuation of all 
51 



802 PATHOLOGICAL PUERPERIUM. 

the contents of the peritoneal cavity — bacteria, exudate, etc. — is indicated; but 
only in a very few cases is this heroic resource efficacious. The most promising 
cases are those in which a sudden escape of pus, etc., has inoculated the entire 
peritoneum, such as occurs in rupture of an abscess. The surgical treatment of 
general peritonitis will be discussed more fully later (page 819). In the absence 
of surgical intervention, palliative treatment may give some relief. The inflated 
abdomen may be subjected to warm packs; tympanites may be relieved by 
means of a long colonic tube. Stimulants of all kinds and appropriate nutriment 
are indicated. Fortunately, as already stated, the end of these patients is often 
peaceful. 

Consecutive Lesions from Venous Extension. 

XII. Metrophlebitis, Septic Phlebitis, or Septicaemia Venosa. — The micro- 
organisms which cause infection may gain access to the circulation in two 
ways: by the lymphatics (Fig. 972), as already noticed, and by the veins 
(Figs. 953, 954). The placental site is naturally most likely to be the starting- 
point of the latter process. The diffusion through the general circulation of 
pyogenic organisms and the transportation of these organisms to distant tissues 
and organs give rise to a long train of symptoms and complications which 
are usually grouped under the name pyemia. Some of these complications, 
however, may occur as the result of other varieties of sepsis; e. g., endocarditis 
is sometimes seen in connection with the lymphatic form of sepsis and arthritis 
may occur when the infection is due to gonorrhea. 

Uterine and Para-uterine Phlebitis. — Pathology: Thrombosis of the 
uterine or pelvic veins is not a rare occurrence (Fig. 993). Uterine re- 
relaxation predisposes to its development. Normally a thrombus becomes 
organized and converted into an impervious cord of tissue, or a channel may 
be formed and the circulation re-established. When a thrombus becomes 
infected, which naturally happens most frequently at the placental site, it 
disintegrates, and fragments may be carried, to distant parts of the body. 
Septic phlebitis may occur when the vessel is surrounded by infected tissue. 
In this case the endothelium proliferates and thrombi occur. Thrombi 
resulting from phlebitis may remain organized, but usually become puru- 
lent; and we then have abscesses in the uterine wall and the extension 
of the process along the veins of the pelvis. When in a case of endome- 
tritis the necrosed endometrium at the placental site is removed, the 
thrombi are found to be but little affected. Extension of endometrial infection 
along the placental thrombi does not ordinarily occur. Organization of the 
thrombi is to be regarded as Nature's safeguard against infection, and probably 
organization in the deeper layers has already occurred before labor. When, 
however, the organisms possess a high degree of virulence, or when they gain 
access to the placental sinuses before or early in the course of labor, the thrombi 
remain soft and permit the propagation of the bacteria, and cases of severe 
infection may be marked by the breaking-up of thrombi already organized. 

Etiology: The usual causes of sepsis are, of course, operative. Manipulations 
about the placental site seem to constitute a predisposing cause. This type 
of infection has often been noticed in sepsis from retained placenta, in cases 
of placenta prasvia, and after manual separation of the placenta. Infection 
occurring early in labor, before the organization of the placental thrombi, is 
especially apt to result in uterine phlebitis. Symptoms: These generally appear 
rather late in the puerperium, perhaps at the end of a week or two, although 
they have been noted three or four days after delivery and as late as three 
weeks and more. There is a sudden rise of temperature to 103 or 105 F., and 



MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 803 

the pulse becomes rapid. A chill is not usually present. The fever soon 
becomes remittent or intermittent, profuse sweats occur at intervals, and 
there are evidences of great prostration. Diagnosis: Bimanual examination 
shows no subinvolution or special sensitiveness or exudation as in pelvic peri- 
tonitis or cellulitis. In some cases sudden and severe hemorrhage may occur 
from the disintegration and dislodgment of infected thrombi. The diagnosis 
is based upon the symptoms mentioned above, together with the negative 
results upon external and bimanual examination. Prognosis: This is grave, 
not only on account of the danger inherent in the condition, but of the various 
complications which may ensue in the course of a metastatic pyemia. Treat- 
ment: There is practically but a single indication in this affection — the prevention 
of metastasis. This is best fulfilled by absolute rest in bed. The least effort, as 
in having the bedding changed, may bring on a chill. It may happen at times 
that the loosening of the thrombi as a result of their suppuration is attended 
by hemorrhage (secondary post-partum hemorrhage). The uterus and vagina 
in these cases must be tamponed, and ergot should be given in large doses. 
If the tampons do not arrest the hemorrhage, intrauterine injections of hot 
acetic-acid solution, 2 to 6 per cent., may be used with vaporization as a last 
resort. 

Femoral Phlebitis, or Phlegmasia Alba Dolens. — This condition 
is still called "milk-leg" by the laity, and was formerly supposed to be 
due to metastasis of milk. It is characterized by venous obstruction and 
enormous swelling of the leg. Pathology: It occurs in two forms — the thrombo- 
phlebitic and the cellulitic. The first is much more common. The two varieties 
may be combined, since a phlebitis may lead to inflammation of surround- 
ing structures, and, vice versa, a cellulitis may cause phlebitis or thrombosis. 
The student will notice that phlegmasia may occur as a complication either 
of uterine phlebitis or of cellulitis — much more commonly, however, of the 
former. The thrombo-phlebitic form may arise in two ways: either by the 
extension of a septic inflammation of the walls of the vessel from the placental 
site, with resulting clotting of blood in the vessel, or by primary thrombosis. 
According to Widal, micro-organisms are especially prone to attack the wall 
of the femoral vein near Poupart's ligament, the circulation being notably 
sluggish at this point, and particularly so when the patient first assumes the 
erect position after delivery. Etiology: The condition is usually to be regarded 
as a result of septic infection. The method of extension is made clear by the 
pathology. It is possible that it is occasionally non-septic in origin. Among 
the causes which may predispose to non -septic thrombosis may be mentioned 
slowing of the circulation, as in varicose veins. Symptoms: In the thrombo- 
phlebitic form the symptoms usually appear two or three weeks after delivery, 
and often after the patient has been up for a few days. As in other forms 
of infectious phlebitis, there are fever and perhaps chilly sensations and a chill. 
The tongue is coated and there are evidences of gastro-intestinal disturbance, 
loss of appetite, constipation, eructations, nausea, and vomiting. There is a 
feeling of weight and stiffness in the leg. Pain in the calf of the leg is often 
a prominent symptom. There may be tenderness along the course of the 
femoral vein which may be marked by a red line. Sometimes other superfi- 
cial veins present similar signs. The leg swells rapidly from below upward 
and soon attains an enormous size. When the swelling is at its height, the 
skin is so tense as not to pit on pressure. In the cellulitic form the symptoms 
are in many respects similar, but the swelling is from above downward and 
there are the accompanying evidences and previous history of pelvic cellulitis, 



804 PATHOLOGICAL PUERPERIUM. 

The left leg is affected oftener than the right. In some instances though be- 
ginning in one leg, the other after a brief interval is also affected. 

The foregoing lesions have been considered because they frequently occur 
in cases of metastatic pyemia, but it is easy to see that the list might be in- 
definitely multiplied. Wherever an infected embolus finds lodgment, metastatic 
abscesses may occur. The liver, kidneys, and spleen, and even the brain and 
eye, have been so affected. Parotitis has been observed; multiple abscesses in 
the muscles and connective-tissue and diffuse cellulitis may occur. Pleuritis 
and pericarditis are common. 

Treatment: The patient should be kept perfectly quiet in bed and all manipula- 
tions should be avoided in order to prevent embolism. The leg should be 
elevated and wrapped in cotton. A nutritious diet is indicated, but over- 
stimulation should be avoided on account of the danger of embolism. The 
patient should remain in bed for two weeks after the subsidence of the swelling. 
The resulting oedema is best treated by the application of a bandage. In the 
cellulitic form abscesses are likely to develop in the femoral region, and should 
be opened as soon as practicable in order to avoid the fistulas which are apt 
to occur. 

Many local remedies are advised for this condition. Among them are: paint- 
ing along the course of the swollen veins, once daily or upon alternate days, 
with tincture of iodine; wrapping the limb in 2 per cent, carbolic acid solution 
or a solution of hamamelis; the local application of the ointments of belladonna 
and mercury either alone or in combination; and the use of various strengths 
of ichthyol in aqueous solution. Of these, I have found a 25 to 50 per cent, 
ichthyol solution to give the best results. In some cases I have used it even 
undiluted. 

XIII. Specific Diseases. — Originating Ixtragexitally. — Here belong three 
diseases which are capable of producing diffuse primary inflammation of the 
genital passages, followed by toxemia or bacteriemia. The disease is contracted 
in most cases from an individual having the same affection ; and herein it differs 
from ordinary infection, which does not represent the extension of a specific 
infectious disease. It must, however, be remembered that in the pre-antiseptic 
period, when puerperal fever was epidemic, propagation occurred from one 
individual to another ; and that a generation ago it was taught by some authori- 
ties (Fordyce Barker) that childbed fever was essentially a specific disease. 
The three specified infectious processes which may originate intragenitally in the 
puerperium are gonorrhea, erysipelas, and diphtheria. The focal affections con- 
cerned are gonorrheal urethritis, vaginitis, cervicitis, Bartholinitis, etc.; diffuse 
erysipelatous 'vulvovaginitis; and diffuse diphtheritic vulvovaginitis. Excep- 
tionally these affections may also produce consecutive focal lesions — endome- 
tritis, salpingitis, peritonitis, etc. (1) Gonorrhea: According to Ahlfeld, the 
gonococcus is found with surprising frequency in the vaginal secretions of a preg- 
nant woman. It is, however, usually present in small numbers. (Fig. 963.) But 
after delivery we may find in the same subject that the number has greatly 
augmented. This rule is believed to hold good for the endometrium, tubes, and 
peritoneum; so that when a puerpera develops clinical gonorrhea, we are not 
to think first of an infection from without. The latter, however, is possible; for 
among certain strata of society, men are known to practise copulation with 
recently delivered women. Our knowledge of the focal lesions of gonorrhea in 
the puerperium does not seem to be commensurate with the importance of the 
subject or with our numerous opportunities for study. Bumm does not mention 
a puerperal gonorrheal vaginitis or urethritis. For him puerperal gonorrhea 



MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 805 

appears to be originally an endocervitis. During the process of dilatation the 
infant is exposed to infection; and it is thus that most cases of ophthalmia 
neonatorum are contracted. After delivery the gonococcus, having become 
mobilized, migrates into the cavum uteri and thence to the tubes. The progress 
of the infection is, however, subacute ; differing thereby from ordinary infection; 
and as a result morbidity from gonorrhea occurs late in the puerperium. The 
chief focal lesions, from the clinical standpoint, are salpingitis, parametritis, and 
especially perimetritis; and when either of these affections develops, say two or 
three weeks after delivery, we should always suspect gonorrhea. Constitu- 
tional reaction when present is almost always due to suppuration — a mere surgical 
fever. In rare cases gonococcus-sepsis has occurred with metastatic phenomena. 
For the management of the focal affections of gonorrhea, see the articles on 
ordinary parametritis and perimetritis and works on gynecology. (2) Diphtheria: 
This disease originating intragenitally develops very rarely in the puerperium. 
The recorded cases of diphtheroid vulvitis, vaginitis, and endometritis are almost 
always due to pyogenic bacteria. When true diphtheria is present, it does not 
appear to produce characteristic focal affections, and the diagnosis has been made 
partly by the discovery of the bacillus, and partly by the appearance of diphtheritic 
membranes in the fauces. If the entire vagina is covered by membrane true 
diphtheria is suggested ; since in ordinary pyogenic infection the false membrane 
forms only upon puerperal wounds. But it is also stated that in true diph- 
theria the membrane may appear only in patches upon wounded surfaces. 
According to Bumm, the infection begins in abraded surfaces, but is rapidly 
generalized until it involves the entire genital tract. A high degree of toxemia 
results, but in the recorded cases no associate infection or sepsis occurred, so 
that the outcome was favorable. The membrane is expelled by subjacent sup- 
puration. As a rule, the disease represents an inoculation from the fingers of 
the medical man. These lesions should be managed on general surgical princi- 
ples, and antitoxin should be administered. (3) Erysipelas: It has usually been 
believed that a puerperal woman exposed to erysipelas contracts ordinary puer- 
peral fever, owing to the apparent identity of the streptococcus erysipelatis and 
streptococcus pyogenes. However, these women sometimes contract true ery- 
sipelas which begins in the cutaneous aspect of the vulva. Some authors 
mention a diffuse inflammation of the genital tract. Ahlfeld mentions an ery- 
sipelatous inoculation of birth-traumatisms. Good descriptions of all these 
focal affections are difficult to find in literature. We may expect to see bac- 
teriemia develop in these cases. Whenever a puerpera is attacked by ordinary 
facial erysipelas, we do not usually see an implication of the genitals. (4) Mis- 
cellaneous: Theoretically any infectious bacterium might set up local intragenital 
lesions in the puerpera. The bacillus of tetanus produces no known local altera- 
tion in the puerperium; hence this condition may be discussed under toxemia. 
When germs like the bacillus coli and pneumococcus cause focal affections they 
are indistinguishable save by the microscope and by cultures from ordinary pyo- 
genic infection. 

Originating Extragenitally. — Of the acute infectious diseases, a certain 
number tend to cause focal affections of the genitals ; so that if a puerpera should 
contract one of these diseases we naturally expect to see the formation of hematog- 
enous genital lesions. Thus cholera and other severe diseases produce endome- 
tritis, which, occurring in the recent puerperal uterus, might readily cause hemor- 
rhage. (Vinay mentions only a single case of post-partum hemorrhage in connec- 
tion with puerperal cholera.) Variola should give rise to a specific vaginitis as 
well. 



806 PATHOLOGICAL PUERPERIUM. 

Metastatic Focal Infection. 

Metastatic Lesions. — These develop only after the establishment of bacteri- 
emia, with which they are necessarily associated. Speaking generally, when a 
woman has once become septic her condition should not differ materially from 
that of septic patients in general; and the subject of metastases might well be 
left to general treatises on pathology. Most authors describe some of the more 
commonly occurring and important metastases in this connection, such as endo- 
carditis, pneumonia, various dermatoses, etc. According to Lenhartz, pulmo- 
nary abscesses, as a rule, represent the only form of suppurative metastasis ; next 
in frequency come intramuscular and intra-articular or periarticular lesions, 
affecting by preference the knee. Very rare metastases are those of the eye 
(panophthalmitis) and meninges. Other metastases are renal and splenic in- 
farcts, cutaneous hemorrhages, and pustular eruptions. An important lesion of 
sepsis not always classed among ordinary metastases is endocarditis, which is in 
itself responsible for metastases of the eye, meninges, etc. 



BLOOD-STATES OR GENERAL CONDITIONS. 
Simple Blood-state or General Condition. 

I. Sapremia. — Sapremia is a blood or general state characterized by the ab- 
sorption of decomposition-products of putrefying tissue. While often spoken of 
indifferently as toxemia, it is of a different character from the toxemia of bacterial 
origin. While the saprophytes, which set in motion the putrefactive changes in 
the dead tissue, secrete poisonous substances, these must be greatly overshadowed 
in importance by the decomposition products of the tissues themselves. Sapre- 
mia is therefore a sort of ptomainemia. The substances which by their decom- 
position furnish these toxic substances are varied, comprising retained placenta 
and decidua, pent-up lochia, the retained ovum or fetus in missed labor, por- 
tions of gangrenous uterus, fibroid tumors, etc., etc. The necrotic surface of 
puerperal ulcers is also a source of sapremic intoxication, and according to some 
authorities, this is even true of the tissue cast off during normal regeneration of 
the endometrium. 

Lenhartz believes that pure sapremia is not so frequent as has been believed, 
and that a bacteriemia often coexists. If he is right, sapremia is but a form 
of sepsis. Clinically the phenomena of sapremia depend upon the amount of 
poisonous matter absorbed. In the most fulminant cases we see the picture 
of a most intense toxemia. There is a chill, followed by high fever, headache, 
vomiting, and complication of the higher nervous centers, as shown by motor 
excitement and delirium. Meteorism is present, as a rule, so that the dyspnea 
of fever is increased. The pulse may reach 160. In the most fulminant forms 
the patient may die in the first twenty-four or forty-eight hours or she may 
linger for one or two weeks. There is, as a rule, no tendency to compromise 
permanently important organs, so that in pure sapremia striking improvement 
follows the removal of the putrefying material. In fatal cases the same altera- 
tions are found as in non-metastatic septicemia. 

Every degree of sapremia may be encountered between the acute fulminant 
type and the "one-day" or even "one-hour" rise of temperature seen in a large 
proportion of normal puerpera. 

Of considerable interest in this connection is the possibility of a different 
type of sapremia due to intestinal resorption incidental to the prolonged consti- 
pation of the puerperal week when the bowels are not artificially relieved. In 



MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 807 

cases in which the woman's bowels have not been relieved before delivery, this 
species of sapremia might antedate labor. It is true that Kustner and Zange- 
meister have apparently shown independently that constipation on one hand, 
and the routine use of castor oil on the other, have no effect on the temperature 
of the puerpera, which when elevated must be due to sapremia from the uterus. 
But a few experiments made perhaps upon phlegmatic peasants will hardly 
convince American practitioners that women in this country do not develop 
a rise of temperature in many cases when the bowels are confined and dis- 
tended with gas. It is true that toxemia of intestinal origin (stercoremia) may 
not be the cause of rise of temperature, for the latter may be due to reflex ex- 
citation of the heat center by the distended bowels. 

II. Bacterial Toxemia. — Pure Toxemia of Bacterial Origin. — This con- 
dition frequently accompanies the puerperium, where it may be caused by the 
ordinary pyogenic cocci, and exceptionally by the tetanus bacillus, Klebs- 
Loefner bacillus, etc. 

Pyogenic Cocci. — Wherever there is an acute local suppurating focus in the 
puerperal genitals, we almost invariably see the development of the toxemia, 
which is a feature of the ordinary surgical or wound fever. While this may 
readily be complicated by sapremia, whenever necrosis or imperfect drainage 
leads to putrefactive changes, a pure toxemia is of common occurrence, especially 
in abscess formation, or wherever saprophytes may be excluded. Walthard and 
others have made the claim that the streptococcus itself, when of low virulence, 
may act as a saprophyte, feeding on dead tissue only and setting up sapremia 
in addition to the secretion of its proper toxins. He thus holds the streptococcus 
responsible for some of the mild resorption fever which is present in a normal 
puerperium. Such a condition would naturally belong to sapremia. It is 
otherwise, however, in some of the severe focal affections of the puerperium. 
Thus in a pure streptococcus endometritis with an efficient leucocyte bar- 
rier against extension by the lymphatics; in a parametritic abscess; in local 
suppurative peritonitis, and even in some cases of fatal general peritonitis, the 
accompanying blood-state is a pure toxemia without any evidence of bacteri- 
emia, whether bacteriological or clinical. It is therefore a mistake to speak of 
such affections as varieties of sepsis. They represent only toxemia, although 
very prone to lead to sepsis. In a certain class of cases the bacteria reach the 
blood, yet clinically the condition is still a toxemia. In the majority of cases 
of bacterial toxemia, recovery is the rule, whether or not abscess-formation 
occurs. An exception is furnished by acute general peritonitis, owing to the 
great extent of surface involved, and the fatal degree of the toxemia, which 
overwhelms the heart. 

Puerperal gonorrhea may be accompanied by toxemia, rarely by bacteri- 
emia as well (gonococcus-sepsis). 

The suppurative focus may be extragenital. This is illustrated by mastitis 
developing near term, the toxemia extending into the puerperium. 

Bacterial Toxemia of Tetanus. — It is well known that the tetanus bacillus 
sometimes reaches the uterus, not only from direct transportation (usually in 
connection with attempts at criminal abortion), but in purely spontaneous labors 
in unexamined women. The tetanus germ does not induce any local lesion, but 
its toxins, formed in situ, are absorbed with the production of the full clinical 
picture of tetanus. Sapremia or sepsis or both may of course coexist. Vinay 
has reported 106 cases, in 37 of which there had been operative interference. 
Hirst has reported three cases in which the disease was apparently due to in- 
jections of unboiled river- water. According to Heyse, a previous septic infection 



S08 PATHOLOGICAL PUERPERIUM. 

is always necessary to pave the way for the tetanus bacillus. This claim has, 
however, been denied. The symptoms and etiology are practically those of 
tetanus in the non-pregnant state. Premature emptying of the uterus seems 
to be a predisposing cause, since the disease develops oftener under these cir- 
cumstances than after labor at full term. In my study of 635 cases of prema- 
ture interruption of pregnane} 7 , no tetanus occurred. The diagnosis can present 
little difficulty, although the affection has been confounded with hysteria. The 
condition is usually fatal. 

Bacterial Toxemia of Diphtheria. — This occurs in primary diphtheria 
of the puerperal genitals, in ordinary diphtheritic angina, etc., as a con- 
current affection. Unless some associate infection or intoxication is present, we 
have the pure toxemia which characterizes simple diphtheria. 

Puerperal Septic Erythema. — As already mentioned, an erythematous 
rash is not infrequently noticed during the puerperium. It may occur in cases 
of profound sepsis or in mild cases. Its principal importance is that it has 
been frequently mistaken for scarlet fever. I have in three instances been 
asked to see cases of so-called puerperal scarlatina which proved to be septic 
erythema. In one case the patient was about to be transferred to the Hospital 
for Contagious Diseases. The rash is attended by itching and sometimes by 
desquamation. It is usually regarded as due to Nature's effort to eliminate 
septic materials by the skin. (See Fever Due to Intercurrent and Complicating 
Diseases.) The existence of a specific infectious erythema has been asserted by 
Simon and Legrain. 

Puerperal Pemphigus. — Very rarely the occurrence of a pemphigoid erup- 
tion in connection with mild cases of sepsis has been noted. The fact that it 
spreads rapidly through a lying-in ward indicates a specific infection of some 
kind. Isolation and the treatment of the coexisting sepsis are of course indi- 
cated. 

Puerperal Septic Neuritis. — This has been described by Mobius, Laury, 
and others. It may occur in the course of a general sepsis, and most commonly 
affects the arms, taking the form of a bilateral median and ulnar neuritis, but 
the involvement of many other nerves has been noticed. The spinal cord 
may be affected. In other cases it may be the result of direct extension of 
the infectious process, as in cases of pelvic exudation. There is also a non- 
septic variety, due to pressure upon the nerve structures by the fetal head, 
the gravid uterus, or instruments. It is most likely to occur in cases of pelvic 
deformity. (See page 835.) The symptoms and diagnosis are the same as in 
the non-puerperal condition together with those of coexisting sepsis. 

This affection must not be confounded with polyneuritis due to the toxemia 
of pregnancy, which may extend into or develop during the puerperium. 

III. Pure Bacteriemia. — This condition denotes the presence of bacteria in 
the blood without the association of bacterial toxins. Naturally the bacteria 
must be of very low virulence. Pure bacteriemia has been found on several 
occasions by Lenhartz in blood examinations made in connection with endo- 
carditis. Despite the constant presence of streptococci in the blood for weeks 
and even months, no further symptoms were produced, and the temperature 
wras practically within normal limits. Pure bacteriemia must occur occasionally 
in the puerperium, as shown in cases of uncomplicated endocarditis, following 
slight genital lesions. In the vast majority of cases, bacteriemia is associated 
with toxemia, constituting septicemia. 



MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 809 



Composite or Septic Blood-states or General Conditions. 

IV. Bacteriemia with Toxemia. — i. Septicemia. — Septicemia is a blood or 
general condition characterized by (a) bacteriemia and toxemia; (6) certain 
clinical phenomena; and (c) certain post-mortem findings. Bacteria cannot 
always be obtained from the blood, but their presence therein is assumed if 
the other conditions are in evidence. When metastatic lesions are present we 
have a special clinical or anatomical variety, but metastases do not necessarily 
occur. Endocarditis when it develops is not usually counted as a metastasis, 
but a complication which is itself a cause of metastatic foci. 

In non-met astatic septicemia the post-mortem lesions are slight, and con- 
fined to cloudy swelling of the kidneys, liver, and heart, with an enlarged and 
relaxed spleen. Clinically septicemia may be ushered in with a chill, followed 
by high fever of remittent type ; or it may develop in a most insidious manner, 
the temperature rising gradually. The pulse-rate varies with the temperature 
and may reach 150. There are great prostration and a cyanotic pallor. The 
disease may be malignant from the start, destroying life in a few days or a 
fortnight or it may extend over many weeks. Clinically it is usually accom- 
panied by severe focal affections. From these primary foci the bacteria and 
toxins continue to enter the blood by the lymphatic route ; hence the course and 
prognosis depend somewhat on the progress of the primary lesion. In a certain 
proportion of cases endocarditis develops, while in others true metastases occur. 
These elements also exert great influence over the ultimate outcome of the 
disease. 

Sepsis with endocarditis and metastatic sepsis do not differ from those affec- 
tions in non-puerperal subjects and need not be dwelt upon. 

In the narrower sense of the term, puerperal sepsis is due to the ordinary 
pus-exciters, principally the streptococcus. Sepsis due to the staphylococcus, 
bacillus coli, pneumococcus, etc., also occurs, as well as does mixed infection. 
Septicemia of a character similar to the ordinary streptococcus type might be 
associated with puerperal scarlatina and erysipelas ; also with gonorrhea. 

Septicemia in the wider sense of the term, not due to the familiar pyogenic 
bacteria, may occur in the puerperium. Here would belong typhoid fever and 
acute general tuberculosis. 

2. Pyemia. — Pyemia is merely a form of septicemia which follows phlebitis 
and suppuration of thrombi. The peculiarity of the primary lesion leads to 
clinical and anatomical peculiarities, for large amounts of bacterial toxins have 
ready and repeated access to the blood, as do likewise pus corpuscles and portions 
of infected thrombi. In ordinary septicemia, when pus enters the blood it is 
usually as a result of secondary ulcerative endocarditis; while in pyemia, the 
pus proceeds directly from the infected uterine sinuses. Ulcerative endocarditis 
is also very common in pyemia. Generally speaking, no absolute distinction can 
be made between the blood-states in pyemia and septicemia. 

Pyemia, like septicemia, may run a fulminant or a subacute course. In the 
first place the large amount of toxins which enter the blood gives the disease 
the character of a severe toxemia which may be fatal before metastases are 
in evidence; in the subacute form, toxemia is less marked and metastatic com- 
plications may succeed one another. 

As a rule, pyemia is characterized by repeated chills, which may occur daily, 
sometimes to the extent of several in a day. The fever curve is irregular and 
either intermittent or remittent. In acute cases the symptoms resemble those 
of acute septicemia; in fact there is no essential difference between the two 
states. (See Metastatic Focal Affections.) 



810 PATHOLOGICAL PUERPERIUM. 

3. Septicopyemia. — This term is sometimes used to denote a special blood- 
state, which is said to be inevitably fatal, but it does not appear just what is 
meant by the term septicopyemia. In former years it was evidently used 
as an equivalent for pyemia. Following modern terminology we shall restrict 
the term to cases in which the blood is infected by the venous and lymphatic 
routes combined. Thus Trendelenburg found that in forty-three fatal cases 
of puerperal fever there were eighteen cases of septicemia, twenty-one cases of 
pyemia, and four of combined lymphatic and venous infection (septicopyemia). 
Clinically such a condition may be regarded as a pyemia. 

V. Sapremic Sepsis, including Gas Sepsis. — Sepsis representing an association 
of bacteriemia and toxemia, the term sapremic sepsis may be used to denote 
several conditions. Thus, in simple sapremia of a fulminating type, the sapro- 
phytes may be found in the blood during life, as shown by Lenhartz. Ordinarily, 
however, the expression sapremic sepsis would imply a mixed or associate condi- 
tion, in which ordinary septicemia or pyemia is associated with sapremia from 
putrefaction of the uterine contents and perhaps of the endometrium itself. Such 
a condition is overwhelmingly toxic, because the blood contains both bacterial 
toxins and the products of putrefaction. It represents a severe and fulminant 
type of disease, and one which should be essentially malignant. Recovery may 
occur, however; Lenhartz's case Xo. 48 represents a sapremic sepsis in which 
sapremia was associated with bacillus coli bacteriemia. The bacterium disap- 
peared from the blood as the case progressed to recovery. In such cases of mixed 
infection removal of putrescible material from the uterus is not necessarily fol- 
lowed by improvement in the lochial discharge, which may remain offensive for 
days, signifying that the endometrium itself is the seat of putrescence. Doubtless 
this severe involvement of the endometrium — mixed putrid and pyogenic endome- 
tritis — is responsible for the associated implication of the blood. Another still 
more formidable type of sapremic sepsis is the so-called "gas sepsis'' — a condi- 
tion which is rare and not fully understood. It is known that most of the 
saprophytes which attack the tissues after death, or gangrenous tissue during 
life, generate gases which may or may not be fetid. Some saprophytes, such as 
the bacillus aerogenes capsulatus, and bacillus phlegmones emphysematosa?, 
appear to be able to attack living tissues and form gas. But the so-called 
tympania uteri maybe due to a variety of causes, and the part played by bacteria 
is not well defined. In many cases which end fatally, it is not easy to decide 
whether the gas-forming bacteria have attacked the tissues before or after death. 
It is admitted, however, that in some of the severest forms of putrid or mixed 
endometritis, gas-forming saprophytes may attack the uterus during life and 
also set up a gas -bacteriemia and gas-forming metastatic lesions. In most of 
such cases ordinary septicemia or pyemia coexists. 



General Coxditioxs with Anomalies of Temperature. 

VI. Simple Hyperthermia. — This condition, also known as pseudo-fever, con- 
sists, as its name implies, of a simple elevation of temperature without any of 
the collateral phenomena of true fever. It has been noticed under a variety 
of circumstances, and is due apparently to a variety of causes. The slight rise 
of temperature following exercise in early tuberculosis, which is generally re- 
garded as a contraindication to voluntary exertion, is held in some quarters to 
be a simple hyperthermia of no practical significance. Slight elevation of tem- 
perature may follow a hot bath. Rise of temperature has been produced by 
suggestion, and by mere nervous excitement. The thermal center is doubtless 



MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 811 

under the influence of emotional and reflex excitation in subjects with nervous 
instability. When we remember that the latter condition is common in the 
pregnant woman and can hardly disappear at once after delivery, it should not 
surprise us to see paradoxical elevations of temperature in the puerpera. Not 
only do we find simple hyperthermia in the presence of nervous excitement 
and physical discomfort (constipation) ; but even in sapremia up to a certain 
degree, rise of temperature is not attended with collateral evidences of fever. 
Simple hyperthermia is not of long duration, as a rule. 

Caution. — It is to be hoped that the student will not infer from the list 
of possible causes of fever which I mention that any of them, except perhaps 
the constipation and reflex influences, are at all common during the puerperium. 
The undoubted possibility of their occurrence, however, makes it incumbent 
upon the physician in every doubtful case carefully to search for the evidences 
of acute or chronic disease, just as he would in any patient and at any time. 
Typhoid fever and malaria, especially the latter, have been convenient names 
by which to designate the results of improper management of labor and the 
puerperium. When the practitioner realizes that he should either wear sterile 
rubber gloves or disinfect his hands and arms as carefully for a vaginal exam- 
ination as for a laparotomy; that vaginal examinations should be as infrequent 
as possible, and should be preceded by careful cleansing of the vulva and 
that all unnecessary manipulations should be avoided after delivery, — he will 
find that fever, except transient rises of temperature from constipation and 
reflex causes, will be of the rarest occurrence, and that he will seldom be called 
upon to make the differential diagnosis between puerperal sepsis and other 
febrile affections. 

Some difficulty arises in classifying the causes of pseudo-fever, since in 
some cases the fever is of reflex origin, while in others it is not so or only 
in part reflex in character. I believe, however, that the following arrange- 
ment will be of service in enabling the student to recall and to differentiate the 
different kinds of fever. 

i. Constipation. — That constipation may cause a rise of temperature during 
the puerperium is a matter of everyday experience (Fig. 975). Doubtless this 
fever is partly reflex in character from the distention of the bowel and 
consequent local discomfort, but it is also toxic, as shown by the head- 
ache and general malaise which accompany it . This condition was recog- 
nized and described by Gilman, Schroeder, Roswell Park, and others, as the 
result of the absorption of products of decomposition. It is not peculiar to 
the puerperium, but there is, at this time, a special predisposition to it, on 
account of the accumulation of feces in the later weeks of pregnancy and 
the sluggish intestinal action during the puerperium, the causes of which have 
already been considered. It is also a well-known fact that a prolonged re- 
cumbent posture predisposes to obstinate constipation. The treatment consists in 
the proper regulation of the bowels during the later weeks of pregnancy, by atten- 
tion to the diet, and the administration of a laxative on the evening of the second 
or morning of the third puerperal day, followed, if necessary, by an enema. 
(See Management of the Puerperium and Diet of the Puerperal Woman, 
pages 748 and 758.) In the presence of fever or headache, reasonably attribu- 
table to constipation, the prompt administration of a saline cathartic is in- 
dicated. It is wise, however, not to wait for the action of a cathartic, but 
to give at once a copious enema of soapsuds. Subsequent attention to diet 
is important. 

2. Hyperthermia from Reflex Irritation. — That a sharp but usually transient 



812 



PATHOLOGICAL PUERPERIUM. 



rise of temperature may be produced by reflex irritation is a fact with which the 
obstetrician soon becomes familiar (Fig. 977). In this case the fever is, without 
doubt, due to the effect of the exciting cause upon the nervous system, but 
the modus operandi is largely a matter of speculation, and need not be discussed 
here. It is a matter of clinical experience, however, that the circumstances 
attendant upon pregnancy, labor, and the puerperium, tend, especially in patients 
of the neurotic type, to an exaggeration of reflex nervous excitability. Fever 
of reflex origin is usually to be traced to some source of pain or discomfort 
purely physical in character, and not of infectious origin. The most frequent 
source of trouble in this respect is overdistention of the breasts with milk. 








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fol- Fig. 975. — Fever due to Constipation 

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1. Mammary Irritation: Among the sources of reflex irritation, distention 
of the breasts is perhaps the most frequent and important. The so-called 
" milk fever" of the older writers has already been alluded to, and is now re- 
garded as obsolete, but it is nevertheless true that the extreme and painful 
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duration, disappearing with the removal of the cause. The various kinds of 



MORBID CONDITIONS ORIGINATING IN THE PUERPERIUM. 813 

infection may be excluded by the methods described in connection with the 
diagnosis of the different varieties of sepsis, but this will not usually be necessary. 
Especial care should, however, be taken not to mistake a beginning mastitis 
for overdistention of the breast, since the treatment of these conditions is 
radically different, and a mistake is likely to result disastrously for the patient. 
The diagnosis of mastitis is considered elsewhere (page 828). As regards treat- 
ment, the child should be put to the breast and the surplus amount of milk 
removed, if necessary by the breast-pump, or better by gentle massage under 
hot stupes; but all rough handling of the breast must be avoided. If necessary, 
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FLUENZA. 



In- Fig. 977. — Fever due to Reflex Irri- 
tation of Caked Breasts. Relieved 
by massage through hot stupes. 



for a time. A properly applied breast bandage may be a source of comfort 
to the patient. Abscess of the breast is considered elsewhere as a form of 
local sepsis. 2. Sore Nipples : The pain attending a cracked or fissured 
nipple, especially during nursing, may cause a transient rise of temperature, 
although in such a case we would ordinarily suspect infection through the 
nipple (Fig. 986). 3. Rupture of the Uterus: Among the causes of fever 
which may be regarded as purely reflex in character, may be noted the rise 
of temperature which may almost immediately follow uterine rupture. Al- 
though fever due to septic peritonitis and other infectious conditions may, 
of course, follow later, it seems reasonable to ascribe the first rise of temperature 



814 PATHOLOGICAL PUERPERIUM. 

to reflex irritation. 4. Retrodisplacements of the Puerperal Uterus: 
A rise of temperature due to this cause and promptly disappearing after replace- 
ment I have observed as late as the fourth week. 

It is obvious that the list of possible causes of non-septic fever may be 
indefinitely extended. Colic, the peristaltic action evoked by cathartics, the 
discomfort attending the passage of hard fecal masses, or the prolonged retention 
of urine, might cause, in patients of the neurotic type, a fever, disappearing 
promptly with the removal of the cause. Exposure to cold is an occasional 
cause, and I have observed fever, excitement, and neurotic symptoms late 
in the puerperium from the presence of a tapeworm, which was subsequently 
secured. 

3. Hyperthermia from Neurotic Conditions. — The possible occurrence of fever 
as the result of organic nervous disease has already been noted. It remains to 
notice the role played by functional neuroses in the production of fever during 
the puerperium. Emotional Excitement: This frequently causes a tran- 
sient rise of temperature. Fright, grief, anger, excessive annoyance from any 
cause, may have this effect. As in the case of reflex irritation from causes 
purely physical, the modus operandi is not well understood. These cases are 
most likely to occur in patients of the neurotic type. Hysteria : The occa- 
sional, though very rare, occurrence of sustained high temperature in hysterical 
cases cannot be doubted. The diagnosis is to be made by eliminating the 
various forms of sepsis, by the previous history of the patient and by the 
absence of the general symptoms due to septic infection. The treatment is 
obvious. During the puerperal period all visitors except the patient's mother 
or husband should be excluded, and every source of annoyance and excitement 
eliminated as far as possible. The importance of securing for the patient a 
sufficient amount of undisturbed sleep has been referred to in connection with 
the management of the puerperium, and cannot be overestimated. In cases 
of hysteria, in addition to measures adapted to the morale and surroundings, 
the bromides and other nerve sedatives will be of service. 

VII. True Fever. — True fever is characterized by a number of phenomena, 
of which hyperthermia is the chief. It begins in general with a precursory 
hypothermia, sometimes expressed by chilliness or rigors, and after its establish- 
ment pursues a certain course with intermissions or remissions. In most cases 
it is due to a toxic principle in the blood, which is akin to the albumoses. An 
albumose-reaction can be obtained from febrile urine in the majority of cases. 
This substance, while affecting the heat center, also acts upon the vaso-motor 
center as well, so that fever is accompanied by circulatory phenomena, chiefly 
local congestions. Since true fever is due to the action of a toxin, we find it 
associated as a rule with malaise, headache, pain in the limbs, anorexia and 
other evidences of toxemia. The pulse-rate increases, as a rule, with the tem- 
perature. A certain group of symptoms is caused by the persistent high tem- 
perature and increased interchange of gases, as thirst, dryness of the mouth, 
scanty urine, etc. In the puerperium it is important to discriminate between 
mere hyperthermia and true fever, for the former, as a rule, requires no inter- 
vention directed to the uterus. The fever of sapremia, toxemia, septicemia, 
etc., is essentially one and the same, being due either to products of putre- 
faction or bacterial toxins, both classes of substances being akin to toxalbu- 
moses. 

VIII. Hypothermia. — Hypothermia and fever do not necessarily accompany 
the blood-intoxications and infections of puerperal morbidity. Instead we 
may encounter hypothermia, under which term we may, for simplicity's sake, 



TREATMENT OF PUERPERAL INFECTION. 815 

include normal temperatures when present in severe systemic affections. Len- 
hartz states that hypothermia is known to occur under three conditions, i. 
Severe collapse or adynamia such as complicates perforation of the uterus and 
peritoneum (as an accident of forceps delivery). He relates a typical case in 
which a woman lived for seven days without rise of temperature, a feeble eleva- 
tion occurring just before death. 2. Subfebrile periods in ordinary cases of 
sepsis. These occur under various circumstances. Thus in a case of what 
proved to be combined putrid and infectious endometritis, emptying the uterus 
resulted in four days of normal temperature, after which pyogenic endometritis 
asserted itself with fatal sepsis. When pyemia leads to secondary suppurative 
foci in the joints, empyema, etc., evacuation of the pus may be followed for 
a time by normal or subnormal temperature. 3. Terminal hypothermia. This 
phenomenon is sometimes seen just before death in severe cases of sepsis or 
pyemia. 

TREATMENT OF PUERPERAL INFECTION. 

1. PREVENTIVE TREATMENT. 

This has been largely discussed in connection with the management of 
labor, and it cannot too often be repeated that when the management of normal 
labor is regarded as very largely identical with the preventive treatment of 
puerperal infection, the latter will be of the rarest occurrence. I sum up 
the preventive treatment of puerperal sepsis under four heads: (1) General 
hygienic measures. (2) Asepsis of patient, physician, and accessories. (3) 
Limitation of internal examinations and manipulations. (4) Antistrepto- 
coccic serum. 

(1) Hygienic Measures. — Under this head is to be considered everything 
which tends to fortify the system against disease in general. Good blood 
is the best of germicides, hence the importance of good hygiene during preg- 
nancy; an out-of-door life, good diet, freedom as far as possible from sources of 
worry and care. The correction of anemia by iron and other tonics, the treat- 
ment of any constitutional dyscrasia, should be carefully attended to in order 
to prepare the patient against the inroads of septic infection. Under the same 
heading come certain precautions already discussed elsewhere; e. g., the selection 
of a sunny and commodious lying-in chamber, as far as possible removed from 
toilets, sinks, and plumbing, and securing good ventilation. All these precau- 
tions should be regarded as important because they prepare the patient to 
resist infecting agents; but it should not be forgotten that all the agents thus 
combated do not of themselves act as the immediate causes of infection. Nor 
should the physician forget, in his attention to such details, that the actual cause 
of puerperal infection is contact of wounds in the birth canal with an infected 
agent. 

(2) Asepsis of Patient, Physician, and Accessories. — The patient (see Manage- 
ment of Labor, page 523): The arrangement of the vulval pads and the subse- 
quent cleaning of the external genitals have already been described in connection 
with the management of the puerperium (page 749). The physician: A physi- 
cian who is dressing suppurating wounds, attending cases of erysipelas, scarlet 
fever, diphtheria, or other cases of infectious or contagious diseases, should 
not attend obstetric cases if he can help it. If he is obliged to do so, he should 
take a full bath, change his clothing, disinfect *his hands and arms with special 
care, and make no internal examinations that are not imperatively necessary, 
and then only with his hands encased in sterile rubber gloves. The method of hand 



816 PATHOLOGICAL PUEBPERIUM. 

disinfection has been described (page 156). It is needless to say that any 
man who practises obstetrics should himself be free from infectious or conta- 
gious diseases; he should be cleanly as to his habits, should bathe fre- 
quently, should wear clean clothing, should keep his nails trimmed short and 
carefully cleaned, and should be particular even to fastidiousness about the 
care of his hands. The use of a sterile operating gown or duck suit and of 
sterile rubber gloves is an additional safeguard (page 157). The nurse: As 
already stated, she should be free from any contagious or infectious disease, 
especially suppurative coryza or skin disease, nor should she recently have 
attended a case of infectious or contagious disease. She should also have 
had a full bath and change of clothing, paying special attention to the hair, 
which should be well washed with soap and water, then with plain water, and 
then with a bichloride solution (1 : 10,000). She should be expressly forbidden 
to give douches or practise any internal manipulations while cleansing the 
external genitals. Instruments and water used: All instruments or other appli- 
ances which are to come ui contact with any part of the parturient tract should 
first be thoroughly scrubbed with green soap and water, especial attention being 
paid to any cracks or crevices, and then boiled for not less than twenty minutes. 
They should then be removed by an aseptic instrument and kept in a solution 
of carbolic acid or lysol until needed, or, better, used directly from the boiler 
or sterilizer. All instruments which cannot thus be sterilized should be avoided. 
Catheters and douche tubes should be of glass or metal, preferably glass. If 
it becomes necessary to use a Barnes bag, a gum catheter, or similar appliance, 
it should first be thoroughly washed with green soap and water and then steril- 
ized by boiling or by steam under pressure. All water used for immersing 
instruments, washing the external genitals, and giving douches should first be 
boiled. 

(3) Limitation of Internal Examinations. — This is perhaps the most im- 
portant precaution of all, as has been fully stated in connection with the manage- 
ment of normal labor (page 529). It is of special importance if the physician 
has recently been in attendance upon any case of infectious or contagious 
disease, or if his hands have been contaminated by septic discharges of any 
kind, and in all cases during and after the third stage of labor, even if sterile 
rubber gloves are used. 

It is, of course, true that in many cases it is impossible to carry out all 
of the above rules in practice. Skilled nursing and sterile accessories are not 
always available. But if the physician will but remember that septic contact 
is the one source of infection, if he insists upon and personally supervises cleanli- 
ness and antisepsis of the external genitals and their immediate surroundings, 
and avoids all unnecessary interference, especially after delivery, very satis- 
factory results may be secured even among most unfavorable surroundings. 

(4) Antistreptococcic Serum. — The preventive power of Marmorek's serum 
was tested by Wallich upon 383 women who bade fair to have a septic puer- 
perium either by reason of certain acts of exposure or accidents of delivery. De- 
spite the precaution, 56 developed phenomena of infection. 



2. CURATIVE TREATMENT. 

The non-surgical treatment of puerperal infection comprises, at the present 
day, supporting measures, antipyretics, and various specifics and quasi-specific 
remedies of more or less doubtful utility, such as Marmorek's serum and Credo's 

silver ointment. 



TREATMENT OF PUERPERAL INFECTION. 817 

(i) Supporting Measures.— These differ in nowise from the same class of 
remedies employed in the treatment of typhoid fever, pneumonia, etc. The 
patient receives whisky or brandy according to the state of the pulse, with 
strychnin, ^ grain, every three or four hours, and digitalis as necessary. Quinin 
is much less used than formerly, although individual authorities continue to 
prescribe it. Diarrhea should not be checked, and many authorities even 
advocate the routine use of aperients in puerperal infection, especially calomel 
and laxative salts. Vomiting requires cracked ice and champagne. In order 
that the patient's vitality may be kept at the highest point, it is necessary 
that she should receive a plentiful supply of nutritious food. Milk, koumyss, 
broths, eggs beaten up with milk or broths, beef -juice, panopeptone, beef 
peptonoids, and so on, should be administered in as large quantities as the 
patient can assimilate. It is well, also, to try the effect of solid food — e. g., 
raw oysters, meat, etc. In prolonged cases it is of great importance to a patient 
suffering from sepsis that the stomach should be in such condition as to retain 
an abundant supply of nutritious food and stimulants, which is a cogent reason 
for not giving medicines whose utility is doubtful and which may derange 
that organ. Good results are obtained from the subcutaneous injection of salt 
solution in large quantities. A more direct method, of course, is that of venous 
infusion. From one to two pints may be injected several times during the 
day. (See Part X.) Washing out the colon by means of decinormal salt 
solution is worthy of further trial, not only upon theoretical grounds, but 
because occasional favorable results have been reported in puerperal as well 
as non-puerperal forms of sepsis. Finally, a very valuable remedy in these 
cases is oxygen, which should be inhaled in large quantities and systematically. 
The use of ergot to promote involution, and by causing uterine contraction 
to prevent the transmission of infection through the lymphatics, has already 
been mentioned and constitutes a rational method of treatment. I am in- 
clined to believe that it prevents also the absorption of pathogenic germs which 
may be present in the vagina. The absorbent power of a lax uterus is very 
marked. 

(2) Antipyretics. — Quinin, phenacetin, and other antipyretics have been 
advocated by various observers. In a process like acute peritonitis, which 
runs a rapid course and in which death is due to other causes than fever, they 
are of little or no service, and may do harm by causing cardiac depression and 
disturbing the stomach. In prolonged cases — i. e., in pyemia — they are some- 
times beneficial, and when fever is attended by headache they may afford relief. 
Under such circumstances they should be given tentatively if bad effects on 
the heart and stomach are not noticed. If the coal-tar derivatives are given, 
those least depressing to the heart should be selected, and it is well to give 
a stimulant at the same time. Hydrotherapy offers a better means of reducing 
fever in these cases. There is considerable testimony as to the efficacy of the 
cold bath, and if it is not, as occasionally happens, too depressing to the patient, 
its use is to be advised. My practice is to rely mainly upon the wet pack, cold 
sponging, and the abdominal coil as antipyretics. For local inflammatory ten- 
derness, whether from endometritis, affections of the parametrium, or general 
peritonitis, the intermittent application of cold, as the coil or ice-bag, applied 
to the fundus, is usually a wise precaution. 

(3) Specific Medication. — Antistreptococcic serum: Orrhotherapy in puerperal 
fever is still on trial. While many have abandoned it, others continue to 
employ it. It is necessary to exhibit the remedy in large doses. The initial 
injection should be 0.7 oz. (20 c.c), while the total daily dose should be 2.1 oz. 

52 



818 PATHOLOGICAL PUERPERIUM. 

(60 c.c.) in desperate cases. In one class of cases prompt and permanent 
recovery appears to follow the treatment, while in others improvement is either 
wanting or may be only temporary. The use of this serum is, of course, irra- 
tional without evidence that the streptococcus is present in pure culture. In 
communities where bacteriological tests of the lochia cannot be obtained the 
serum may be used in any desperate case as a last resort. Crede's ointment: 
This preparation of silver, which was introduced in 1895, as a general remedy 
for sepsis, has been used to a limited extent in puerperal infection. As appar- 
ently hopeless cases of the latter may suddenly take a turn for the better, 
a few seemingly successful tests of a remedy prove nothing. On account of 
the desperate nature of the disease, however, the remedy may be tried, because 
it is harmless and can be exhibited by simple inunction. From 15 to 45 grains 
(2 to 3 gm.) at a time should be rubbed into the internal aspect of the thighs 
once or twice daily. The duration of the inunction should be twenty minutes 
and the site should be afterward covered with rubber tissue.* Mercurial oint- 
ment: This is still employed in some European clinics, the drug being pushed 
to the point of salivation. By most authorities, however, this method is justly 
ignored. Abscess of fixation: This method of treatment, which is evidently the 
same in principle as that of the seton and issue formerly used, has been 
tried in a few cases of puerperal sepsis with apparent benefit. Professor Fochier, 
of Lyons, who is the advocate of this mode of treatment, states that in 
certain cases of general infection we see the patient's condition improve suddenly 
and materially after the development of a localized suppuration. This he 
terms "fixation abscess." In cases of grave sepsis he attempts the production 
of an artificial abscess by injecting turpentine under the skin. If no pus forms, 
the prognosis is hopeless. If a large abscess can be formed and allowed to 
increase at will without opening, the patient undergoes a change for the better. 
Intravenous infusion of formaldehyde solutions: On January 13, 1903, Barrows, 
of New York, reported to the New York Obstetrical Society the cure of a severe 
case of puerperal sepsis, by the infusion of a 0.02 per cent, solution of formalin 
or 0.008 per cent, solution of formaldehyde gas into a vein of the arm. The 
remedy has since been used with varied results by many. Further experience 
is necessary to prove its usefulness. Pry or' s Iodine Treatment: An investigation 
of the uterine discharges and the contents of the pelvic cavity in cases of puer- 
peral sepsis has resulted in a more definite idea of the conditions which must be 
treated. W. R. Pry or f has operated upon thirty-seven cases, in all but 
one of which streptococci, generally mixed with other germs, have been 
found in the uterine discharge and in all the cases streptococci were found in 
the pelvic cavity. He not only does a curettage in these cases and packs the 
cavity with iodoform gauze, but he also does a posterior section of the vagina 
and packs the cul-de-sac full of iodoform gauze. The results have been uni- 
formly good, and on the third day the germs have in every case been absent 
from the discharges. This excellent result is attributed to the local iodism 
which is caused by the action of the exudates upon the iodoform, thus setting 
iodine free. The absorption of this iodine through the infected lymphatics is 
supposed to have a decided and beneficial effect. The after-treatment of these 
cases is so technical and consumes so much time that it would be difficult to 
secure for it a very general adoption. Attempts are now being made to secure 

* Unguentum Crede, containing 15 per cent, of collargolum, can be obtained in suitable 
half-ounce jars from Messrs. Schering and Glatz, 58 Maiden Lane, New York. Care must 
be taken that an inert preparation is not used. 

t" N. Y. Med. Jour.," Aug. 22, T903. 



TREATMENT OF PUERPERAL INFECTION. 819 

this local and general iodism by more easily effected means. Ichthyol Treatment: 
I have found ichthyol apparently of value in cases in which after clearing 
the uterus of debris, and irrigating, the symptoms still persisted, without any 
marked symptoms of extra-genital infection. After the final irrigation of the 
uterus with a saline solution, the cavity is packed with gauze soaked in a sterile 
solution of ichthyol in water (i to i). It has also been proposed to inject re- 
newal drams of a 50 per cent, solution of ichthyol in water into the uterine 
cavity. With this latter method I have had no experience. I usually have 
the ichthyol gauze in the uterus for twenty-four hours, remove it, irrigate with 
a saline solution and repack. In certain cases to avoid too much disturbance 
of the patient I have left the gauze in the uterus for from forty-eight to 
seventy-two hours. The uterus should not be tightly packed. 

3. SURGICAL TREATMENT. 

(1) Curettage. — This resource, used by many in a routine fashion, is regarded 
by others as a dangerous practice. We sometimes see the temperature rise 
and the disease take a fatal turn after this operation. During an interval 
of ten years Bumm * has seen in his own practice ten untoward results of curet- 
tage: 5 cases of phlegmasia alba dolens, 3 of fatal pyemia, and 2 of fatal peri- 
tonitis. The endometrium should never be curetted in streptococcic infection; 
in the first place, 80 per cent, of these patients recover spontaneously from the 
formation of a protective layer of leucocytes in the decidual lining of the uterus. 
The germs leave the uterus in connection with the necrosis and expulsion of 
the decidua; the use of the curette is therefore distinctly meddlesome. It 
breaks down the defensive wall and allows the streptococci to penetrate into 
the uterus and gain the peritoneum; this being the method by which curettage 
may set up peritonitis. Less virulent streptococci may attack the exposed 
placental site and enter the venous sinuses, there causing purulent disintegration 
of thrombi or perhaps an endophlebitis of the crural vein with resulting phleg- 
masia alba dolens. Curettage, in fact, is indicated only in putrefaction of 
decidual and placental remains with resulting sapremia. Here the results are 
very satisfactory because these saprophytes can exist only on dead tissue. 
Even here, however, the fingers should be used to remove all large masses 
and the placental site should never be curetted. 

(2) Vaginal Incision and Drainage. — Incision through Douglas's pouch in 
acute pelvic suppuration of puerperal origin necessarily presupposes an accurate 
diagnosis which can be made only by bimanual examination under narcosis. 
Kronig warns against the employment of this resource lest a recent adhesion 
be ruptured with subsequent development of diffuse peritonitis. As there is 
no certainty that vaginal incision will lead to evacuation of the pus, the operator, 
according to Kronig, would best pursue the expectant plan. Quite recently 
certain operators have advocated vaginal incision and drainage in acute pelvic 
peritonitis and cellulitis. f A parallel instituted between this procedure and 
the expectant management apparently shows the superiority of the former. 
The majority of authors do not even mention early vaginal incision in this 
connection. The ultimate removal of pus by incision through the Douglas 
pouch, after due waiting for resorption to occur, is permissible if the pus is 
walled off and the patient in good condition. 

(3) Extirpation of the Infected Uterus and Laparotomy. — This is indicated 

*"Ueber die chirurgische Behandlung des Kindbettfiebers," Halle, 1902. 
t "American Journal of Obstetrics," Mar., 1902. 






820 PATHOLOGICAL PUERPERIUM. 

in cases which do not improve after evacuation of the uterus, providing the 
disease is still confined to the latter. Schultze performed this operation success- 
fully for retained placenta, Stahl for suppuration of a myoma in the puer- 
perium, Sippel in putrid endometritis, Prochownik in septic abortion, etc. 
Many of these hysterectomies have been performed in America. Bumm * has 
performed five extirpations of the uterus with two recoveries. The fatal cases 
were all examples of streptococcic infection. The indications for this operation 
are difficult to determine. If one waits for the infection to reach the confines 
of the uterus, as shown by local symptoms in the immediate neighborhood 
of the latter, operation as a rule will result in stump infection and subsequent 
peritonitis. On the other hand, there is a natural hesitancy in regard to per- 
forming hysterectomy in incipient cases, because spontaneous recovery is 
likely to follow any type of infection. The infectious germs may be propagated in 
all directions — into the tubes, veins and lymphatics, and upon the peritoneum. 
Cases of this type are inoperable. Something can be done toward the diagnosis 
' of operability by anesthetizing the patient and a thorough bimanual palpation of 
the tubes, ovaries, and pelvic connective tissue. To perform laparotomy 
as a last resort, in default of precise indications, is not justifiable, although 
now and then a cure may be accomplished. If a puerperal pyosalpinx develops, 
the germ is usually the streptococcus which maintains its virulence un- 
changed. The danger of infecting the peritoneal cavity in attempting to 
remove a pyosalpinx is very great. Miliary abscesses and detached colonies 
of germs may be present in the inflammatory zone which surrounds the tumor. 
Premature intervention in pyosalpinx is strictly contraindicated, for it may 
be that the septic process is about to become localized. In regard to septic 
peritonitis, all our resources — simple incisions, irrigation, and drainage — notably 
fail when a large amount of peritoneal surface is involved. Bumm f cites a 
case in which he made a free incision in the linea alba, took out a portion of 
the intestine, removed all exudate, irrigated the abdominal cavity with many 
quarts of saline solution, tamponed the pelvic cavity with iodoform gauze, 
and finally made counteropenings to secure abundant drainage. These patients 
usually perish rapidly from collapse; enormous numbers of streptococci are found 
post mortem upon the peritoneum of all the abdominal organs. To combat 
peritonitis successfully, laparotomy would have to be performed as soon as 
the disease begins, with removal of the infected uterus at the same time. This 
intervention is too severe for most patients to undergo. The only recoveries 
common in puerperal peritonitis occur in cases of encapsulated collections of 
pus. Pelvic abscess is in itself a favorable termination for puerperal sepsis, 
because it indicates arrest of the infective process. There is little danger that 
the pus will burrow, and incision is indicated only when the original small 
purulent foci have coalesced to form a large abscess. Puncture is more practi- 
cable than incision in these cases. If the abscess is opened at the abdominal 
wall, a counter opening should be made in the vagina, and vice versa. 

(4) Excision of Veins. — The question of the excision of veins as preventive 
of pyemia naturally arises. Autopsies frequently show veins plugged with 
purulent thrombi which were amenable to excision, the lesion being limited 
to a small portion of a single vein; for example, one of the spermatics. Physical 
exploration under deep narcosis will sometimes enable the operator to feel 
the infundibular ligament of the pelvis as a thick, indurated cord. The technique 
required for the excision of these veins is not difficult. Bumm has operated 
three times, but unfortunately without success. In one case a septic phlegmon 

* Vide supra. f Vide supra. 



CLINICAL TYPES OF PUERPERAL MORBIDITY. 821 

was found in association with the thrombo-phlebitis ; in a second, which prom- 
ised well, the left spermatic vein was the seat of suppuration. It was resected 
within wide limits and the pyemic chills ceased within three days. The patient 
succumbed, however, from a fresh purulent focus in the same vein. In the 
third case, as in the first, the phlebitis was accompanied by an extravascular 
phlegmon. Trendelenburg succeeded in saving a patient by this operation in 
1902.* This form of intervention appears to be justifiable as a last resort. 

(5) Atmocausis. — Sneguireff's method of vaporization has been suggested 
by Diihrssen f for septic or putrid endometritis. As this form of intervention 
must necessarily produce obliteration of the uterine cavity with consecutive 
atrophy of the organ, it could be employed only in women near the climacteric, 
and even then solely as a last resort. The technique is very simple. A boiler 
heated by alcohol has a metallic supply tube attached which is introduced 
into the uterine cavity through a fenestrated catheter which is surrounded in 
turn by another tube of non-conducting material for the protection of the 
cervix. The contact of the steam with the uterine cavity should not exceed 
one and a half to two minutes. The pain is insignificant, so that no anesthetic 
is required. I have had no experience with this method. 



(D) CLINICAL TYPES OF PUERPERAL MORBIDITY. 

Introduction. — Without a definite understanding of the various focal affec- 
tions and blood conditions, it is impossible to understand the clinical pictures 
which puerperal morbidity may assume. The number of these conditions is 
very large, although they readily fall into certain categories. Thus we may 
have certain local lesions with little or no general reaction, and general sepsis 
with but little local disturbance. We may have local putrefaction of dead 
tissue associated with sapremia; local suppuration (abscess) with toxemia (fever 
of suppuration); local inflammation with bacterio-toxemia ; metrophlebitis with 
so-called pyemia; various combinations of the preceding, etc. 

The General Symptoms of Puerperal Sepsis. — There are certain symptoms 
common to most cases. The most prominent of these is fever. An elevation 
of temperature, commonly occurring about the third day, is usually the first 
sign that attracts attention. The pulse is increased in frequency, and when 
the increase is not in proportion to the amount of fever, we have a valuable 
diagnostic symptom. In puerperal sepsis the pulse ratio is greater than with 
fever due to other causes. Liebermeister % gives the pulse-rates which should 
result from corresponding temperature markings: Temperature 98. 6° F., pulse- 
rate 78; temperature 100. 4 F., pulse-rate 88; temperature 102. 2 F., pulse-rate 
97; temperature 104 P., pulse-rate 105; temperature 105 F., pulse-rate 109; 
temperature 107 F., pulse-rate 121. A chill or chilly sensation may be present, 
but is frequently absent, especially in the milder types of infection. It may, 
however, be present in any variety of sepsis, and is not necessarily indicative of 
metastasis, as it was at one time thought. Pain and tenderness in the pelvis are 
not constant symptoms, and the same may be said of distention of the abdomen 
due to paralysis and consequent relaxation of the intestines, of nausea and 
vomiting, a coated tongue, constipation or diarrhea, special changes in the 
urine, sleeplessness, and delirium. Headache is a prominent symptom, as are 
disturbances in the process of involution, shown by a soft, flabby uterus. 

*" Munch, med. Wochenschr." t "Arch. f. klin. Chirurgie," lxii, No. 4. 

% " Vorlesungen iiber specielle Pathologie und Therapie," Band in. 



822 PATHOLOGICAL PUERPERIUM. 

Diminution in the quantity of the lochia, especially for twenty-four or forty- 
eight hours at the outset of the attack, is quite constant, but a marked foul 
odor to the lochia, except in cases of retained secundines, is not necessarily 
present. Foul odor is often absent in the severest types of puerperal sepsis. 

I would give the following symptoms as most pathognomonic of the various 
types of puerperal sepsis, aside from a bacteriological examination of the blood 
and the secretions of the genital tract: (i) Fever; (2) increase in pulse-rate out 
of proportion to the amount of fever; (3) sensitiveness of the pelvic organs 
to pressure; (4) disturbed involution; (5) persistent diminution in the amount 
of the lochia. When the symptoms begin a few hours after labor, they are 
probably due to infection before or during labor. If no symptoms appear 
by the end of the fifth day, the patient may usually be regarded as 
out of danger from sepsis. There are exceptions to this rule, however, as 
will presently be noted. The student should remember that while in the 
majority of cases the infection starts from the vagina or cervix, the symptoms 
first noticed are usually those of an endometritis. 

1. Purely Local and General Conditions. — The local and general conditions already 
described may be encountered independently of each other in the puerperium. Simple 
non -infected birth-traumas may heal without any general reaction, but if they are at all 
extensive, even normal regeneration may be attended with slight sapremia or hyperthermia. 
The occlusion of patulous uterine veins by aseptic thrombosis may be regarded as a simple 
local process, even when the thrombus extends for some distance along the veins (benign 
form of phlegmasia alba dolens) . More or less absorption of the putrescible residue of the 
uterine contents may occur without the coincidence of putrid endometritis, but if toxic 
products occur beyond a certain limit, the latter condition should be present to some extent. 
Slight degrees of bacterial toxemia from saprophytes may also occur without the production 
of local lesions. In this connection we may mention puerperal tetanus. If the bacterium 
of this disease happens to be present in the puerperal uterus, its toxins may be absorbed 
with production of the full clinical picture of tetanus. It is only necessary to state here 
that the affection is particularly mortal; and neither the free use of antitoxins, nor hys- 
terectomy has been able to save life. Some pathologists affirm the existence of a pure 
pyogenic bacteriemia occurring independently of local infection. The germs reach the 
blood without any accompanying toxins, and their presence is discovered by accident, after 
they have set up an ulcerative endocarditis. Pathologists also mention a cryptogenous 
septicemia of the puerperium, in which the streptococcus is alleged to reach the blood 
without first causing a local lesion in the genitals. If the full picture of septicemia is pres- 
ent, it is difficult to understand the locality of the breeding- ground of the germs, which is 
requisite for their rapid multiplication and the formation of toxin. It is known, however, 
that septicemia may follow such an insignificant lesion as a stye. In puerperal septicemia 
without demonstrable local lesion, we cannot, of course, be sure as to the primary focus, 
whether intragenital or extragenital. 

2. Simple Hyperthermia. — Simple rise of temperature in the puerperium is a condi- 
tion which merits the most careful study. In inexperienced hands it has often led to a 
premature diagnosis of sepsis and to unnecessary and mischievous irrigation and curettage 
of the uterus. We have already stated under hyperthermia that mere elevation of tem- 
perature, without collateral evidence of fever, is presumably harmless. It is known to 
occur under four conditions, to wit: constipation, reflex irritation, neurotic conditions, 
and mild_ sapremia or bacterial toxemia. These have been discussed individually. (1. 
Constipation, page 811 . 2. Reflex irritation, page 811. 3. Neurotic conditions, page 814.) 

3. Mild Degrees of Sapremia and Bacterial Toxemia. — It appears that while a' certain 
quantity of the toxalbumoses of decomposition or bacterial secretion causes the entire 
picture of fever, quantities below a certain point manifest themselves only by disturbing 
the heat-center. In this manner is produced a large proportion of the petty morbidity 
of the puerperium. This is known generally as "resorption fever," and especially as 
"one-day fever." It ma}^ begin at any period of the puerperium, and sometimes 'does 
not last over a few hours. It seldom exceeds 100. 4 F. (38 C.) , and as a rule is discovered 
only in connection with systematic thermometry. Manv obstetricians regard all fever 
in the puerperium as essentially sapremia or toxemia, and hence do not recognize the ther- 
mogenic influence of constipation, emotional excitement, etc. Yet the latter are recog- 
nized by general practitioners as frequent causes of rise of temperature, especially in the 
course of diseases. 

4. Fully Developed Sapremia. — In this group the large amount of putrescible mate- 
rial present in the uterus leads to the development of well-marked sapremia. The clinical 
picture differs considerably, varying with the cause. Numerous varieties are recog- 
nizable. As a rule, the quantity of toxic material formed is sufficient to set up putrid 



CLINICAL TYPES OF PUERPERAL MORBIDITY. 823 

endometritis. (a) Lochiometra (see page 775). (b) Putrefaction of Retained Placenta 
or Deciduae; Putrid Abortion, etc.: This condition may give rise to intense sapremia, 
which may disappear entirely after evacuation of the uterus. Pyogenic infection of the 
endometrium may develop secondarily, and even in the absence of this factor, the putre- 
factive process may extend to the tissues of the uterus. Manual extraction of the pla- 
centa, while apparently an indication of necessity, is peculiarly liable to set up pyogenic 
infection at the placental site, (c) Missed Labor with Putrefaction of Fetus; Putre- 
faction of Fetus from Arrested Labor, etc.: In putrefaction of the entire fetus, the woman 
can hardly escape developing a high degree of putrid endometritis and sapremia. Death 
often occurs before the fetus can be extracted. Such cases are usually spoken of as acute 
sepsis, and the latter may often coexist, but putrescence of the uterus and sapremia are 
amply sufficient to cause death, (d) Putrefaction of Adherent Placenta, or Fibroid Tumor 
of Uterus; Pressure Gangrene of Uterus: Affections of this character may be ranged to- 
gether as representing a partial gangrene of the uterine substance. Hysterectomy is gener- 
ally regarded as a legitimate procedure in these cases. 

5. Fully Developed Bacterial Toxemia and Fever, but without Sepsis. — Examples of 
ordinary surgical wound or pyogenic fever make up a large portion of the morbidity of 
the puerperium, and are distinctly benign in character, because the leucocyte barrier 
prevents general infection. The suppuration may be confined to primary foci or con- 
secutive lesions may also be present. A few bacteria may find their way into the blood 
without causing true septicemia. The amount of toxemia varies with the extent of the local 
mischief, which in turn is due to the number and virulence of germs. The focal lesions 
comprise puerperal ulcers of the vulva, vagina, and cervix; benign pyogenic endometritis; 
parametritis, with or without abscess formation; localized peritonitis which may also be 
plastic or purulent; and general peritonitis, the latter, however, being a malignant con- 
dition, even in the absence of sepsis. Exceptionally urinary infection or salpingitis may 
result by direct extension from the birth-tract. As the general condition is tolerably 
constant, there are as many clinical modifications as there are combinations of focal lesions. 
We may, however, isolate the following: (1) Limitation of the pyogenic foci to the birth- 
tract proper. (2) Secondary implication of parametria. (3) Secondary implication of 
perimetrium. (4) General peritonitis. 

1. Limitation of Pyogenic Foci to Birth-tract. — Obstetricians in general teach that if 
one portion of the birth-tract is attacked, others are quite certain to be involved. Thus 
infected cervical tears infect the endometrium, on the one hand, and vulval birth wounds 
on the other. But statistics (Lenhartz) show that vulva, vagina, and cervix may be in- 
dividually involved, without any subsequent contamination of the other organs. Doubt- 
less extension occurs in proportion to the number or site of the wounds. Infected lacera- 
tions represent simple suppurating wounds, while pyogenic endometritis is equivalent to 
a suppurating cavity. The pyogenic surfaces all tend to heal by granulation. 

2. Secondary Implication of Parametria. — This represents either a secondary lymph- 
angitis or cellulitis on one or both sides of the uterus. Clinically a distinction must be 
made between the plastic and suppurative forms. We thus have two clinical types: (1) 
Suppurating wounds of the birth-tract with simple cellulitis or lymphangitis, and (2) the same 
with pelvic abscess. The presence of the latter naturally modifies the clinical picture. 

3. Secondary Implication of the Perimetrium. — The pelvic peritoneum is involved 
either by contiguity, as when pelvic cellulitis extends directly to this membrane, or be- 
cause it forms a part of the lymphatic apparatus and is attacked by continuity as a result 
of lymphangitis. Whenever the peritoneum is involved, the clinical picture of the peri- 
toneal reaction develops. If, in addition, pus forms, we have pelvic abscess again. In the 
absence of an abundant and thorough series of clinical and anatomical observations it is 
impossible to give a definite idea of the more prevalent clinical types. Lenhartz men- 
tions the frequency with which lacerations of the cervix set up parametritis, and again 
speaks of the common association of parametritis with peritonitis. Data as to the fre- 
quency of abscess formation in the pelvic cellulitis and peritonitis are not available. Since 
this class of cases is essentially benign, the diagnosis must be made intra vitam. 

4. General Peritonitis. — Although this condition may develop as a mere consecurive 
lesion to endometritis or parametritis without the occurrence of sepsis, proving fatal through 
the degree of toxemia, it is probably best to rank it among the pictures of true sepsis by 
reason of its great mortality and frequent occurrence as a phase of sepsis . 

Puerperal diphtheria may be ranked as an excellent example of genital lesions with 
severe bacterial toxemia. 

6. Septicemia (Bacterial Toxemia and Bacteriemia). — This group differs from the pre- 
ceding in a single respect, to wit, that owing to the superior virulence of the bacteria, 
the leucocyte barrier and similar defences are overcome, and germs reach the blood 
in such numbers and virulence as to cause clinical septicemia. Yet this distinction 
may be more apparent than real; for under ordinary circumstances it is probably the 
toxins which destroy life, the occurrence of the bacteriemia merely indicating a higher 
degree of morbidity. An important question to be asked is this: Are negative results 
in bacteriological tests of blood so to be interpreted as to indicate that the blood is really 
sterile? If we answer this affirmatively, it must mean that a certain proportion of cases 
of apparent sepsis are simply cases of bacterial toxemia. Another question of pertinence 
is this: What injury do bacteria inflict upon the blood? We have already seen (page 775) 



824 PATHOLOGICAL PUERPERIUM. 

that in certain numbers they may circulate in the blood for weeks and months without 
causing morbidity; and yet they are well able to set up lesions under particular circum- 
stances. We have already called attention to the fact that by attacking the endocardium 
— which they are prone to do — they may transform a case of simple septicemia into one 
of metastatic pyemia. Moreover, when present in the blood in sufficient numbers, they 
may cause capillary embolism with resulting hemorrhages and infarcts. Such lesions 
have been seen in the retina, the skin, and other localities. When the pyogenic cocci in bac- 
teriemia are thus localized, they should be able to set up small suppurative foci ; and 
such a sequence undoubtedly occurs, especially when the staphylococcus is circulating in 
the blood. Pustular eruptions have been noted in very rare instances, which admit of 
no other causation. Yet metastases of this character cannot be compared clinically with 
those which occur when pus corpuscles and bits of thrombi, swarming with bacteria, find 
their way into the blood as a result of pyogenic phlebitis (pyemia proper) . 

From what has been said it appears that the distinction between pure bacterial toxe- 
mia, septicemia, and pyemia is clinical and not pathological. A high degree of toxemia 
is present in all three conditions, and is responsible for many of the graver symptoms. 
Bacteria may also be present in the blood in all three conditions; but in toxemia proper 
they are few in number and not necessarily pathogenic; in septicemia they may set up 
endocarditis or cause capillary embolism; in pyemia alone extensive metastases occur. 
Whenever septicemia leads to endocarditis, a clinical type of pyemia results, with metas- 
tases to the eye or brain. 

7. Septicemia as a Clinical Phenomenon. — All authorities describe an acute type of 
sepsis which may prove fatal in twenty-four or forty-eight hours. There is every reason 
to believe that the fulminant character of this affection is due to the toxemia, which may 
be sapremia, bacterial toxemia. It is difficult to see how bacteriemia alone could contrib- 
ute to the cause of this condition. According to Ahlfeld and others, we may expect 
to see this type of affection when there is a very large amount of putrefying material, 
such as is found in putrefaction of the entire fetus, pressure-gangrene of the uterus and 
the like. I have already alluded to a fulminant type of sepsis which quickly destroys 
the patient without causing any local lesions ; the existence of such a condition is asserted 
by a number of authorities. Sepsis associated with general peritonitis is naturally a highly 
malignant affection, for the local lesion is in itself sufficient to cause death in the great 
majority of cases without coincident sepsis. 

Generally speaking, septicemia is a blood-state superadded to any of the local pyogenic 
affections already described. To the bacterial toxemia which is associated with such 
lesions, a bacteriemia is added. While simple toxemia, even if severe, tends to recovery, 
the reverse is true when living bacteria are present in the blood in large numbers. Yet 
it is not always easy to see wherein the added danger lies, save when endocarditis is set up, 
or sapremia or general peritonitis is associated. The same insufficiency of the leucocyte 
barrier which permits bacteria to enter the blood, also makes possible a toxemia of a higher 
degree and greater persistency, which eventually overwhelms the patient. Bacteriemia, 
save when it leads to the implication of vital organs, such as the heart or brain, is rather 
an index of malignancy than a fatal complication. From this standpoint septicemia is 
clinically a higher and more persistent degree of toxemia than the bacterial toxemia which 
accompanies benign suppurative focal lesions. The increased toxicity of the blood results 
in one case from the breaking down of the leucocyte barrier (which, in its turn, is due to 
the great virulence or number of germs or the diminished resistance of tissues) ; in another, 
from the large amount of toxins which reach the blood when metrophlebitis is present ; in a 
third, from the coexistence of a high degree of sapremia resulting from the presence in the 
birth- tract of large quantities of putrescent material; and in a fourth case, from the ex- 
treme absorption of toxins which occurs in involvement of the entire peritoneum. 

The clinical course of malignant toxemia thus developed is somewhat as follows. We 
have already stated that the patient may succumb quickly to heart-failure. In the less 
fulminant forms the picture is as follows: While in the benign bacterial toxemia of sup- 
puration we have a high fever with its concomitants, which varies with the progress of 
suppuration, disappearing gradually as granulation takes place or suddenly after evacuation 
and proper treatment of the pyogenic membrane, in the malignant toxemia we see numer- 
ous special phenomena, such as progressive heart-failure, as shown by the great weakness 
and arhythmia of the pulse. Endocarditis occurs in about one-fourth of all cases, almost 
always confined to the left side. As a rule, the spleen is considerably enlarged and tender, 
and mild or severe nephritis with albuminuria and cylindruria is a frequent complication. 
The liver will be found enlarged when cardiac insufficiency has developed. The blood in 
the majority of cases will be found to contain bacteria; when it remains sterile, Lenhartz 
does not look upon the negative result as due to faulty technique, but to death of the bac- 
teria while m the blood. Of great significance is the blood-count in septicemia, for there 
is often a notable reduction in the number of erythrocytes. The hemoglobin is also greatly 
reduced. As already stated, sepsis, whether fatal or not, tends to set up a blood-state 
which may amount to acute pernicious anemia or leukemia. Much has been written of 
the various types of fever which develop in septicemia, and which sometimes appear to 
vary with the species of pathogenic bacterium involved. But the consideration of sepsis 
in all its manifestations does not belong to obstetrics, but to general pathology. Pyemia 
proper is the form of septicemia which is associated with metrophlebitis. There are two 



ANOMALIES OF THE BREASTS. 



825 



clinical types — non-metastatic and metastatic. Non-metastatic pyemia as a blood-state 
does not differ from septicemia. The local lesion may consist of metrophlebitis, with or 
without extension of the process into the continuous venous trunks, with which may be 
conjoined periphlebitic abscesses. But the degree of toxemia may be sufficient to cause 
death, despite the absence of endocarditis, peritonitis, or metastases, as in cases reported 
by Lenhartz. The repeated and recurring chills of pyemia are a measure of the severe 
and persistent intoxication of the blood. In metastatic pyemia the clinical pictures may 
be infinite in variety, depending upon the location and order of evolution of the metastases. 
In many cases, however, metastasis is limited to the lungs, so that this should form a well- 
marked clinical type (pyemia with metastatic pulmonary abscesses). In another type 
the metastases tend to be localized in the locomotive system (intra-muscular and peri- 
articular abscesses). Visceral metastases (liver, spleen, kidneys, etc.) may develop. When 
pyemia is accompanied by endocarditis, the latter may be responsible for metastases to 
the eye or the brain. Aside from the tendency to cause metastases and endocarditis, pyemia 
is very frequently associated with peritonitis, the latter being due to direct extension of 
the metrophlebitis. Naturally, in the most fatal cases of pyemia these individual varieties 
may be merged into one. Thus Lenhartz cites a case of putrescence of the endometrium 
with extensive thrombophlebitis, purulent general peritonitis, and metastatic abscesses 
of the kidney and spleen. 

From all that has been said the phenomena which accompany complications of septice- 
mia and pyemia, septicemia and sapremia, and pyemia and sapremia, will readily be under- 
stood. Such associations, when well marked, have an eminently fatal tendency. 



VIII. ANOMALIES OF THE BREASTS. 

i. Absence of Mammae, or Amazia. — This anomaly is extremely rare. It 
has been said that absence of one breast occurs only in women, and absence 
of both only in monsters who are otherwise extremely deformed. A stunted 
condition of the breasts is often 
associated with imperfect de- 
velopment of the true sexual 
organs. 

2. Hypertrophy. — This an- 
omaly is also rare, and gener- 
ally occurs in those quite young. 
One breast is often larger than 
the other. Lactation sometimes 
diminishes the size of the hyper- 
trophied breasts. 

3. Supernumerary Breasts : 
Polymazia or Polymastia. — This 
condition is rare. These extra 
mammas are generally found on 
the chest below the normal 
gland and more median in 

situation. However, instances are on record of their being found in the most 
varied situations. This fact does not admit the theory of reversion. Men 
seem to exhibit this phenomenon as frequently as women, if not more so. 
Heredity seems to account for it in some instances. Supernumerary breasts 
vary in size from a minute collection of glandular tissue to a full-sized breast 
secreting the normal amount of milk (Fig. 344). 

4. Anatomical Anomalies of the Nipples (Fig. 979). — (1) Congenital absence 
(athelia): This condition rarely occurs. When acquired, it is generally due to 
injury, or it may result from suppuration of the infantile breast. (2) Flat and 
inverted nipples {microthelia) : This anomaly maybe either congenital or acquired 
and is common a the result of corset pressure. It should be recognized at 
the examination of pregnancy (Fig. 979). The treatment consists in drawing 




Fig. 



979. — Comparison of Faulty and Normal 
Development of the Nipples. 



826 



PA THOLOGICAL P UERPERI UM. 



out the nipple with the fingers or breast-pump in the latter part of gestation. 
Breast-shields may obviate the difficulty of nursing. Artificial feeding may 
become necessary. (3) Fissured nipples (Fig. 986): The nipples are exposed to 
the discomfort of chafing from the continual changes of dryness and moist- 
ure to which they are subjected. Many parturient women suffer from this 
trouble. There is danger of the entrance of micro-organisms and of subsequent 
inflammation. Treatment is chiefly prophylactic, as elsewhere described (page 
194). Exposure of the nipples to the ordinary atmosphere is excellent to 
harden them. Boric-acid solution as a wash is most useful. After ulceration 
has once been established vigorous measures are necessary. 



IX. ANOMALIES OF THE MILK SECRETION. 

1. Deficient Secretion : Oligolactia or Agalactia. — A deficiency of milk in 
the nursing woman is quite common, but a complete suppression is not 
frequent. Deficiency may be caused by a congenital or acquired defect in 
the structure of the mammary glands. Ill health, advanced age, or obesity 

may also be a cause. It sometimes 
occurs after a premature or still- 
birth, and also follows a previously 
abundant supply of milk, and is then 
often due to continuous overexertion. 
The milk secretion is mainly depen- 




Fig. 980.— Ordinary Breast-pump. 




Fig. 081. — Nipple Shield 



dent upon the general condition of the mother and upon the diet. Treatment: 
If the cause is some defect in the structure of the breasts, treatment is of 
little avail. If, however, there are other causes, such as ill health, overwork, 
etc., a carefully regulated diet, change of air and scene, tonics, and other 
hygienic measures are often effective. Gentle massage has been followed by 
beneficial results. Crabs, whether hard- or soft-shelled, have been found the 
best milk producers among foods. Many kinds of sea food, especially shell 
fish, seem to have the same influence. Boiled fresh beets, without vinegar, 
are one of the best vegetables. 

2. Excessive Secretion. — (1) Polygalactia: This condition is one of an excessive 
amount of milk. Congestion and engorgement of the breast are not necessarily 
present. ^ Its occurrence is not frequent. It may develop during the first part 
of lactation and gradually subside. If it continues, to the great discomfort 



DISEASES OF THE BREAST. 827 

of the mother, means should be taken to overcome it. Treatment consists in 
regular times of nursing, in emptying the breasts by massage, the breast- 
pump, or compression. The diet may be restricted and the amount of fluids 
diminished. Laxatives should be given. (2) Hyperlactatio 1 1: . Lactation pro- 
longed beyond the ninth month may result in an exhausted physical condition 
of the -mother, which is sometimes termed tabes lactealis. This habit is most 
prevalent in the lower walks of life. The mother may develop symptoms of 
anemia accompanied by neuralgic pains. Nervous manifestations often follow. 
The symptoms are profound anemia and pains in the upper extremities during 
nursing. Phthisis also may develop. The child must be weaned at once. Tonics 
must be administered to the mother, while a change of air will be found very 
beneficial. (3) Galactorrhea: This affection consists in a continuance of the 
milk secretion with constant flow between the periods of nursing. The milk 
is of poor quality. Both breasts are generally affected. In certain cases the 
quantity of milk is excessive, resulting in exhaustion of the mother. The 
causes are unknown. It may be a nervous affection. The almost continuous 
flow of milk with loss of strength and interference with nutrition brings about 
anemia, emaciation, and nervous disorders. The treatment is unsatisfactory. 
Iodide of potassium and ergotin are recommended; atropin locally (1 gr. to 1 oz. 
of glycerin) I have found of great value. Return of menstruation sometimes 
increases the flow. Belladonna ointment is preferred by some; I have found 
it less certain than atropin in glycerin or vasogen. A lotion for bathing the 
nipples, consisting of a 5 per cent, solution of cocaine hydrochlorate in equal 
parts of glycerin and water, often assists in the treatment. Saline laxatives to 
keep the bowels open are of benefit. Electricity is not always attended by the 
results hoped for. 

3. Qualitative Anomalies. — The quality of the milk is also variable, depending 
upon many conditions. The diet of the mother is a very potential factor in in- 
fluencing the quality of the milk. This should, as a rule, be about the same as 
she has always been accustomed to; it should comprise plain, mixed foods 
with a slight excess of fluids ; milk taken between meals is beneficial ; the inter- 
vals between nursing periods should be carefully regulated; excessive emotion 
of any kind is always to be avoided. 



X. DISEASES OF THE BREAST. 

i. Areolar Inflammation. — Inflammation and even abscess of the glands of 
Montgomery may occur, but may be prevented by cleanliness or treated by in- 
cision. 

2. Congestion and Engorgement. — Engorgement and congestion of the breasts, 
" caked breasts," usually occur on the third day; the pressure and irritation being 
so great as sometimes to cause pyrexia. The treatment consists in securing 
profuse serous discharges from the intestines with saline cathartics, in the appli- 
cation of heat to the breasts in the shape of hot stupes under pressure, and in 
emptying the breasts by digital massage through hot stupes (Figs. 982, 983, 
984). Saline catharsis, moist heat with pressure, and rest are the principles 
in the treatment of caked breasts. 

3. Sore Nipples. — Simple erythema, excoriation, erosion (Fig. 985), fissures or 
cracks, and eczema of the nipples are all included under the term " sore nipples," 
and all these conditions can usually be prevented by proper attention to the nip- 
ples during pregnancy and the early puerperium. The prophylactic treatment 



828 



PATHOLOGICAL PUERPERIUM. 



consists in the preparation of the nipple for lactation during pregnancy. During 
the later months the nipples should be washed daily with soap and water and 
carefully massaged with sterile vaseline and alcohol. (See page 194.) The cura- 
tive treatment consists in careful cleansing after each nursing with boric-acid 
solution; in the use of a nipple shield (Fig. 981); in the application, of bismuth 
and castor oil, compound tincture of benzoin, oxide of zinc, or nitrate of 
silver to the affected part. 

4. Mastitis; Mammary Lymphangitis; Galactophoritis. — Varieties: Three 
varieties may usually be recognized: namely— (a) subcutaneous, (b) parenchyma- 
tous, (c) submammary (Fig. 
986). M astitis was formerly 
of common occurrence, but 
since its infectious nature 
has been recognized it is 
much less common. It 
occurs more frequently in 
primiparas and during the 
second and third weeks of 
the puerperium, but may 
occur late in lactation. It 
is rare after the fourth preg- 
nancy. Etiology: All forms 
of mastitis are to be regarded 
as forms of infection. The 
infecting agent is - usually 
Staphylococcus aureus, less 
often the streptococcus. 
Staphylococcus albus is 
found in the secretions of 
healthy women in from 80 
to 94 per cent, of cases, and, 
as a rule, is of no patholog- 
ical importance to either 
mother or child (Olshausen 
and Veit). The starting- 
point of infection is usually 
a fissure or an erosion of the 
nipple, but the milk ducts 
may become infected with- 
out this. Occasionally the 
process starts from an abrasion of the areola or skin surface of the breast. 
Infection by micro-organisms circulating in the blood has been assigned 
as a cause, but this claim has not been proved. Metastatic abscesses of 
the breast may, of course, occur in pyemia as the result of thrombotic 
infection. Inspissation of milk, caked breasts, was formerly supposed to 
be the cause, but this has been disproved. It is, in my opinion, a predisposing 
cause. The superficial varieties of mastitis are the result of lymphatic 
infection, while in the more deeply seated it is generally believed that the infec- 
tion is transmitted through the milk ducts. Contact of the nipple or breast, 
especially if eroded or fissured, with unclean hands, clothes, breast-pump, etc., 
and, under certain conditions, with the child's mouth, are all sources of infection, 
(a) Subcutaneous Mastitis (Fig. 986). — This is a superficial and circum- 
scribed inflammatory process usually located under or near the areola. It is 




Fig. 9S2. — Massage and Milking of Distended or 
"Caked" Breasts through Hot Moist Flannel. 
The left hand supports the breast, while the fingers of 
the right hand produce gentle but firm massage radiat- 
ing from the base toward the nipple. 



DISEASES OF THE BREAST. 



829 



always due to infection through the lymphatics. The gland proper is not 
involved. The treatment includes, in the early stages, supporting measures and 
the application of a 50 per cent, ichthyol solution, and, if abscess forms, incision 
and evacuation of the pus, followed by an antiseptic dressing. In this form of 
mastitis it is not always necessary to remove the child from the breast. Care 
should be taken to make the incision either entirety within or entirely without 
the areola, since pigmentation may follow the line of incision. In very rare 
cases the inflammation takes on an erysipelatous type, becomes rapidly dif- 
fused, and is followed by extensive suppuration and sloughing. The axillary 
glands may be enlarged and tender. Accompanying the local process are grave 
constitutional symptoms, 
such as chills, high fever, and 
general prostration. 

Inflammation of the 
Glands of Montgomery. — 
Suppuration of the glands 
of Montgomery within the 
areola sometimes occurs, and 
after rupture obstinate ul- 
cers may form. The glands 
should be incised, the pus 
evacuated, and an antiseptic 
dressing applied. An ulcer, 
if present, should be treated 
on general surgical princi- 
ples. 

(b) Parenchymatous 
Mastitis. — Inflammation of 
the gland proper is usually 
called "parenchymatous 
mastitis." There are, how- 
ever, two distinct forms 
which may be clinically rec- 
ognized : in one the inflam- 
mation begins in the acini 
(Fig. 986), and in the other 
it begins in the interstitial 
tissue (Fig. 986). When it 
begins in the acini, the inter- 
stitial tissue becomes second- 
arily involved, and vice versa. 

If the inflammatory process begins in the parenchyma, the symptoms are a chill 
or chilly sensation and a sharp rise of temperature, perhaps to 104 F. or even 
higher. The patient seldom complains of pain in the breast, but examination dis- 
closes a hard, localized swelling which is tender to the touch but not unbearably 
so ; there may also be a slight redness of the skin. When the process begins in 
the interstitial tissue, it is also accompanied by localized swelling, which, how- 
ever, is not at first well defined. This swelling gradually increases and redness 
of the skin soon appears. In this form of mastitis the temperature rise is 
gradual and a well-marked chill is not common, although chilly sensations 
may occur. Whenever the fever continues for thirty-six hours, it is likely 
that a suppuration is taking place ; a rapid pulse is also considered suspicious. 




Fig. 952. — Massage axd Milking of Distended or 
"Caked" Breasts through Hot Moist Flannel. 
Both hands are used to jointly massage the breast 
and empty the milk ducts. 



830 



PATHOLOGICAL PUERPERIUM. 




Fig. 984. — Massage and Milking of Distexded or "Caked" Breasts through Hot 
Moist Flannel. After softening of the breasts by the methods shown in Figs. 982 
and 983, the fingers of one hand are often sufficient to relieve the tension and empty 
the milk ducts by massaging from the base to the nipple. 



- 




' 



Fig. 985. — Superficial Erosion of the Left Nipple. 



DISEASES OF THE BREAST. 



831 



The prophylactic treatment has already been referred to and applies to all 
varieties of mastitis. It embraces the proper care of the breasts and nipples 
and of the child's mouth, and also the prompt treatment of erosions and fissures. 
Engorgement of the breasts and inspissation of milk should be treated by mas- 
sage through hot flannel, thus softening and relieving tension by milking into 
the flannel (Figs. 982 to 984), by bandaging the breast in such a way as to 
secure firm compression (Fig. 987); and by the administration of a saline 



Interstitial 
Mastitis 



Fissuiv 



Erosion 



Infected 
Milk Ducts 




Retromastitis 
^Submammary Abscess) 



Infection (fa 
Deep lobe 



Infected 
lobules 



Paivnchymatus 
Mastitis 



Fig. 986. — The Extension of Infective Processes in the Breast. 
site of the infection are shown in color. 



The course and 



cathartic. After an inflammatory process has begun, however, manipulation 
can only do harm. 

The curative treatment before suppuration has occurred consists first in re- 
moving the child from the breasts, which should then be supported but not 
compressed. An ice-bag should then be applied over the inflamed area and relief 
may be afforded by compresses soaked in lead-and-opium wash and covered by 
oiled silk or rubber tissue. Free serous movements of the bowels should be early 
secured. These measures, however, should not be allowed to delay timely sur- 



832 



PATHOLOGICAL PUERPERIUM. 



gical treatment, which should be instituted as soon as the presence of pus can 
be determined. 

After suppuration has occurred in cases of subcutaneous abscess, local anes- 
thesia will usually be sufficient, as by cocain or ethyl chloride. In some cases 
general anesthesia will be required, nitrous oxide being most desirable. The 
lowest point of the abscess should be located as nearly as possible and the inci- 
sion should be large enough to admit the finger, and should be in a direction 
radiating from the nipple in order to avoid severing one of the lacteal ducts. 
When practicable the incision should be made in the mammary fold so as to avoid 
an unsightly scar of the breast. The finger should be used to remove broken- 
down tissue and to break up any thin partitions which may separate or only partly 
separate a neighboring pus cav- 
ity. One or more counter-open- 
ings may be made in order to 
secure free drainage. The cavity 
is then irrigated with peroxide of 
hydrogen or some other mild 
antiseptic solution, the opening 
packed with gauze, and an anti- 
septic dressing with a moderately 
firm bandage is applied. In 
from twenty-four to thirty-six 
hours the gauze should be re- 
moved and the openings lightly 
packed. As soon as the discharge 
becomes very slight the gauze is 










A 


16 Inches 




B 






X 


c 

10 

<0 


C 







Cloth folded ready for c 




The dotted lines indicate the part to 
be cut out for arms and neck, with 
centre line repreaenting fold. 




Fig. 987. — Murphy Breast-binder 
in Place. 



Binder completed. Piece Nos. 1 and 2 together and then 3 and 4 together to form the ahonldeo. 



Fig. 988. — Pattern of Murphy Breast- 
binder Used at the New York Maternity 
Hospital. 



removed and the breast firmly compressed. If healing is not satisfactory or if the 
cavity remains full of thick pus, better results may perhaps be secured by the use 
of perforated drainage-tubes, which should not be less than one-fourth inch in 
diameter. The dressing is changed the following day, and after that allowed to 
remain for four days, when the tube or tubes should be removed and shortened 
one-half. It is desirable to remove the tubes within two weeks or less if 
possible. Their prolonged retention is likely to cause fistulae. The aim of 
either method is to secure drainage while at the same time promoting the rapid 
closure of the cavity. As a rule, this is better accomplished by gauze than 



DISEASES OF THE BREAST. 



833 



by drainage-tubes. If the latter should be deemed best at first, it is wise to 
substitute a light gauze packing as soon as circumstances will permit. 

(c) Submammary Abscess (Fig. 986). — This variety of abscess is situated 
under the gland and is the result of the extension of abscess formation from the 
gland proper. The symptoms include pain, which is deeply seated, cedematous 
swelling of the breast and surrounding skin with little or no redness, inability 
to move the arm freely, swelling of the axillary glands, and the general symp- 




Fig. 989. — Y-Shaped Breast-binder Used at the 
Boston Lying-in Hospital. 



Fig. 990. 



-Cross Bandage of on: 
Breast. 





Fig. 991.— Cross Bandage of the Two Breasts. Fig 99: 



-Triangle Bandage of 
One Breast. 



toms of sepsis — chills, fever, and prostration. The breast feels as though it were 
floating on a fluid base. If the pus is not evacuated, it may burrow in any 
direction, and has even been known to perforate the chest-wall and enter the 
pleural sac. I once saw a case in consultation in which a submammary 
abscess had passed unrecognized, death resulting from sepsis and pyemia, 
as was proved by autopsy. The presence of pus is determined by the aspirating 
needle, the breast being drawn upward and held while the needle is introduced 
along the chest-wall beneath the gland. A grooved director is then passed in 
53 



834 PATHOLOGICAL PUERPERIUM. 

and an opening made large enough to admit the finger. The further treatment, 
by irrigation, drainage, etc., is the same as that already described for abscess of 
the gland proper. Special care should be taken to secure free communication 
between a submammary abscess and any abscess in the gland proper. 

Galactocele. — Galactocele is a milk tumor due to occlusion of one or more 
lactiferous ducts, and is a rare condition and of little importance. Puncture of 
the tumor may become necessary, but heat with pressure or massage through 
hot stupes (Figs. 982, 983, 984) will usually suffice. 



XI. BLOOD CONDITIONS. 

1. Puerperal Thrombosis and Embolism. — The blood in pregnancy is pecu- 
liarly coagulable and the circulation sluggish. With these conditions only 
mechanical obstruction is necessary to cause the formation of a clot. This takes 
place in one of the venous trunks and is followed by serious consequences. The 
great importance attaching to thrombi is their liability to break up and form 
emboli. These are carried along to the smaller peripheral vessels. Puerperal 
thrombosis is most common after severe post-partum hemorrhage. Throm- 
bosis of the veins is the most common cause of sudden death both in labor 
and in the puerperium. The femoral, pelvic, and uterine A^eins are the most 
frequent seat of this trouble. Large soft clots may be formed in the event of 
partial detachment of the placenta, or of imperfect contraction of the uterus 
followed by sudden hemorrhage which causes a weakened heart action. These 
clots extend from the larger sinuses toward the heart. Any sudden disturbance 
may dislodge bits of these masses and the blood-current will drive them on as 
emboli. The symptoms of puerperal thrombosis are very sudden. With no 
prodromes there occur a distressing dyspnea and air hunger. The patient 
suffers the throes of suffocation. Cyanosis or pallor spreads over the surface 
of the body, which becomes cold and clammy. The heart is rapid and irregular 
and the pulse small and feeble. The patient fears impending death. This may 
occur with a sudden convulsion. However, recovery may gradually take 
place from the slow absorption of the clot. A rare occurrence is the formation 
of clots in the arteries of puerperal women, instead of, or coincident with, 
the formation of clots in the veins. The symptoms will depend upon the 
particular organ affected. If the cerebral arteries are obstructed, then par- 
alysis and aphasia result; if the ophthalmic, blindness follows. When the clot 
is in the brachial or femoral artery, the respective limb will grow cold with loss 
of sensation and motion, or it may be the seat of neuralgic pain. Pulsation 
is absent below the obstruction and increased above it. If the collateral circu- 
lation is not sufficient for the needs of the limb, then gangrene may occur. The 
diagnosis is usually not difficult. The prognosis is grave. Most of these patients 
die before medical aid can be summoned. The cause of death is disputed, some 
believing it to be cerebral anemia, others cardiac syncope, but it is probably 
asphyxia. For treatment, full doses of cardiac and respiratory stimulants should 
be administered. To relieve pulmonary congestion leeches should be applied. 
The most absolute rest and quiet must be enjoined. The diet must be liquid. 
Oxygen inhalations may be of benefit. 

2. Hematoma. — (See Maternal Dystocia, page 670.) 

3. Puerperal Anemia. — A tendency to anemia probably exists during preg- 
nancy. After the child is born there is a return to the normal condition of the 



BLOOD CONDITIONS. 835 

blood before the completion of involution of the uterus. When this change 
does not occur, the woman becomes markedly anemic. The etiology is not 
clear. It may be due to a serious constitutional disorder. The patient 
may be possessed of slight powers of recuperation. Acute anemia caused 
by hemorrhage may be the forerunner. The symptoms are great weakness 
and pallor, neuralgic pains and backache. There is poor appetite. Hemor- 
rhages are readily caused, and, as a rule, are from the "mucosa. The diagnosis is 
made from the symptoms, physical signs, and blood examination. The prog- 
nosis is uncertain. The disease yields generally to prompt treatment, but if 
neglected it may develop into pernicious anemia. For treatment, strict hygienic 
measures must be enforced and the diet should be nutritious and carefully regu- 
lated. Rest and fresh air are most beneficial. The child may have to be 
weaned. Change of air and scene and mental diversion are very useful. 
Tonics, especially iron and arsenic, are indicated. 



XII. DISEASES OF THE NERVOUS SYSTEM. 

i. Lesions of the Sacral Plexus. — In a generally contracted pelvis, or in one 
with a flattened promontory, or in septic pelvic inflammations or exudates, 
pressure upon the sacral plexus may result during labor or the puerperium. 
Neuralgia, hyperesthesia, paralysis, anesthesia, and atrophy may occur. The 
sacral and sciatic nerves are extremely sensitive to pressure, and movement of 
the leg on the affected side causes extreme pain both in the pelvis and down the 
leg. The prognosis is favorable, and the treatment consists in the cure of the 
septic condition if this is the cause, and in the general treatment of neuralgia. 

2. Puerperal Neuritis and Paralysis. — Definition: Puerperal neuritis is a 
combination of neuritis and paralysis which is single or multiple and of 
toxic origin. The form which develops first during the puerperium is 
believed to be of septic origin. It is also possible for a polyneuritis of 
pregnancy to extend into the puerperal period. Etiology: While puer- 
peral neuritis may depend directly upon a toxin connected with some form 
of puerperal sepsis, it is likely that a predisposition exists in these cases. 
Symptoms: Puerperal neuritis may be general or localized. The latter type is 
more common. Localized neuritis may attack either an upper or a lower limb. 
Puerperal neuritis cannot be distinguished in any way from the non-puerperal 
type. The generalized form is usually a survival from pregnancy, and is often 
associated with uncontrollable vomiting. Its consideration, therefore, belongs 
properly to the Pathology of Pregnancy. The association of polyneuritis with 
insanity known by the name of " Korsakoff's psychosis " has been seen in preg- 
nant women. The localized type of puerperal paralysis is almost peculiar to the 
puerperal period. Its onset is usually preceded or accompanied by fever, with 
evidence of neuritis, such as pain and tenderness. The resulting paralysis may 
be mild and transient, a mere paresis, or it may be of various grades of severity. 
The affection may develop early or late after delivery, thus recalling the various 
periods of supervention of the puerperal psychosis. A favorite locality is the 
ulnar or median nerve. After a period of hyperesthesia, pain, and tenderness 
the sensibility to pain, temperature, and touch begins to diminish and motor 
insufficiency appears with the resulting inability to flex the fingers and adduct 
the thumb, the reaction of degeneration may develop, and in severe cases 
muscular atrophy develops rapidly in the ball of the thumb and in the fore- 



836 PATHOLOGICAL PUERPERIUM. 

arm. In rare cases the nerves supplying the shoulder muscles are the seat of the 
lesion. "When the lower extremities are involved, the peroneal nerve is the 
favorite site and a traumatic paralysis is closely simulated. When paraplegia 
develops, it is believed to be due to bilateral neuritis throughout the sacral 
plexus. This condition is very rare, and when present naturally simulates a 
myelitis. Diagnosis: The recognition of a neuritis should not be difficult. In 
the peroneal nerve the resulting paralysis, however, is not readily distinguished 
from the traumatic type. Qeneralty speaking, neuritic paralysis develops at a 
later period in the puerperium with a history pointing to an acute toxic neuritis 
and a much more rapid supervention of the reaction of degeneration and mus- 
cular atrophy. In paraplegia from neuritis, a spinal origin may be excluded 
by the fact that the integrity of the sphincters is preserved. Prognosis: This 
depends upon the character of the electric reactions, exactly as in the traumatic 
form. Treatment: The initial neuritis must be treated by rest, sedatives, a 
hypodermic of morphin, and counter-irritation. Vinay recommends ergotin 
subcutaneously at this stage, one gram every second day. When the neuritis 
has subsided, the muscles should be subjected to alcohol frictions and massage. 
Traumatic Paralyses. — Definition: Traumatic puerperal paralyses are 
unilateral motor palsies confined to some portion of the distribution of the sciatic 
nerve, usually the peroneus, and due to compression or contusion of the latter. 
They belong to the maternal birth traumatisms and their existence becomes 
apparent soon after labor. Etiology: These paralyses were originally con- 
founded with the results of neuritis and other motor palsies of non-central 
origin. Narrow pelves are believed to furnish a predisposition to these nerve 
traumatisms. Other alleged contributory factors are premature ossification cf 
the fetal cranium, unduly prolonged labor and the arrest of the head in the pelvic 
excavation; forceps extraction, etc. It is nevertheless true that these paralyses 
may result after a labor which is normal in every respect. The great sciatic 
nerve is known to undergo compression in all labors, but the nerve-trunks which 
traverse the pelvis are all protected naturally from undue compression, with the 
exception of the lumbo-sacral, which is exposed to contact with the fetal head, 
and especially with the high forceps as it crosses the pelvic inlet. The fact 
that the peroneus branch of the sciatic nerve is the seat of the paralysis in most 
instances, and that the muscles which it supplies may be seen to contract forcibly 
during the use of high forceps, is sufficient evidence that the deleterious pressure 
is exerted upon the lumbo-sacral feeder of the sacral plexus and sciatic nerve. 
According to Windscheid,* normal spontaneous labor never causes anything 
beyond a slight transitory peroneal paralysis; the severe and perhaps permanent 
injuries being traceable always to forceps or unusual delivery. Symptoms: As 
the fetal head passes the pelvic inlet, the pressure upon the sacral nerves causes 
intense pain throughout the distribution of the sciatic nerves, which subsides after 
delivery. When paralysis follows, an interval of two or three days generally 
elapses before it becomes apparent. Various paresthesias and a sensation of cold- 
ness may precede the motor anomalies. Wlien the latter appear, they take the 
form of a paresis of the thigh muscles, but this is merely a transitory forerunner 
of the actual paralysis which, as already said, tends to affect the peroneus nerve, 
while the thigh muscles and those of the calf retain their functions. The muscles- 
antagonistic to the paralyzed group throw the foot into an equinus position. 
The electric reactions of the affected muscles are normal. The condition found 
is simply a paralysis of the tibialis anticus, extensor communis digitorum, 
extensor hallucis and pedis muscles. When the patient walks, she lifts her foot 

* Sanger and von Herri's Encyclopaedia. 



DISEASES OF THE NERVOUS SYSTEM. 837 

much higher than normal to compensate for the loss of power in the extensors 
of the foot. The gait is characteristic. When the paralysis is of long standing, 
anomalies of sensation are also present in the cutaneous area supplied by the 
peroneus. The sensibility to pain, temperature, and the faradic current is 
more or less abolished, while the reaction of degeneration appears in the mus- 
cles. Trophic changes have been noted in some cases. Prognosis: The general 
outlook in these cases is favorable. Even if the reaction of degeneration appears 
in the muscles, the muscular sense is usually preserved. Treatment: The patient 
should lie in bed and have the affected muscles rubbed and kneaded. If the 
electric contractility is preserved, faradism should be applied once daily. If 
the reaction of degeneration develops, the interrupted galvanic current is prefer- 
able. 

Ocular Paralyses. — These affections vary much in origin and severity. 
They include hemiopia, amblyopia, and amaurosis. In regard to their origin, 
they may be due to the occurrence of pregnancy-kidney, and belong then to the 
pathology of pregnancy. This is true also of paralyses of hysterical origin. 
Strictly puerperal ocular paralyses are due generally to post-partum hemor- 
rhage, and have even been seen after metrorrhagia from abortion. The strictly 
puerperal ocular disturbances appear to consist chiefly of hemiopia. 

Auditory Paralyses. — These, as far as known, originate during pregnancy 
and are due generally to nephritis. 

3. Hemiplegia and Aphasia. — Definition: Puerperal hemiplegia represents 
paralysis of one-half of the body with or without implication of the speech- 
center, and is due directly to the puerperal state. Etiology: Hemiplegia and 
aphasia occurring in the puerperium are due either to extravasation of blood or 
to embolism within the brain, the latter being the more common cause. Ex- 
travasation of blood from rupture of a vessel is a condition not likely to occur 
in the puerperium, and post-partum eclamptic convulsions represent about the 
only species of violence which can naturally occur during that' period. Symp- 
toms: Hemiplegic symptoms are doubtless always present in aphasia, but may 
be so slight and transitory that the loss of speech is practically the only affection. 
The two conditions may coexist in the full development of each. Puerperal 
aphasia is chiefly of the motor type. Prognosis: When these affections are of 
hemorrhagic origin, the outlook is grave, although many patients survive. On 
the other hand, the prognosis is generally favorable in the embolic type, though 
fatalities do occur. In either type a repetition of the pregnancy would very 
likely cause a relapse. Treatment: As we have already seen that these puer- 
peral affections are made possible chiefly by eclampsia and sepsis, the preven- 
tive treatment is embraced in the prophylaxis of these evils. 

4. Myelitis and Paraplegia. — Unlike the intracranial affections just enumer- 
ated, there is no evidence that any of the various recorded cases of spinal menin- 
gitis, myelitis, hematomyelia, etc., which have occurred during the puerperium, 
represent anything beyond, simple coincidence, with the possible exception that 
in a very few instances the lesions of the cord may have been due to puerperal 
sepsis. 

5. Insanity of the Puerperium. — Insanity of pregnancy continued into the 
puerperal period hardly belongs to this category. The essential puerperal 
psychoses do not begin until several days after delivery. A distinction is made 
between the early and late puerperal psychoses, the latter appearing toward the 
end of the puerperal period, or at the period in which the menses would ordi- 
narily be re-established. In regard to the type of this species of maternity- 
insanity, it may be either maniacal or melancholic. A dementia is also recog- 



838 PATHOLOGICAL PUERPERIUM. 

nized by alienists, but it is practically only a terminal stage of one of the primary 
types. 

Etiology. — There is no doubt that the presence of puerperal sepsis in many 
of the cases is something more than a coincidence. Alienists assure us that since 
the introduction of antisepsis into midwifery the frequency of puerperal insanity 
has been marvelously diminished. Many cases of this type of psychosis — such 
as is seen, for instance, in typhoid fever — are said to exhibit more the nature of de- 
lirium than of actual insanity. Again, the coincidence of severe local infection 
has often been remarked, and gives color to the toxic theory; while a further 
coincidence of insanity of the puerperium with puerperal mastitis, phlebitis, and 
other inflammations remote from the genitals helps justify the assumption of 
this point of view. Of other special contributory factors may be mentioned the 
exhaustion which follows deliver} 7 , extreme prostration being a well-known 
cause of certain psychoses or of low delirium. In this connection should be 
mentioned the influence of post-partum hemorrhage. In women already dis- 
posed to insanity the physiological adjustment which follows child-birth is 
doubtless sufficient to set up mental disorder. 

Symptoms. — According to alienists, 80 per cent, of all cases of puerperal 
psychoses begin within the first fortnight, and, generally speaking, the longer 
the period following the first month the rarer the supervention of this type of 
insanity. It is generally stated that puerperal insanity is essentially maniacal 
in contradistinction to the insanity of pregnancy, which tends to the melancholic 
type. It has even been claimed that no less than 90 per cent, of these pyschoses 
are maniacal in type. But, as has already been mentioned, much which passes 
under the name of mania is hallucinatory insanity, and this is especially true of 
puerperal mania. This affection supervenes with prodromes of hallucinatory 
character which affect the patient's mind and cause certain peculiarities of 
disposition and temper. At the same time insomnia also develops. Clin- 
ically the expre'ssion of the affection comprises an attitude of suspicion and 
hostility to others, which often extends to the person of the child. Suicidal and 
homicidal impulses are to be feared. Side by side with the mental aberration 
we often see characteristic physical changes, such as suppression of the lochia 
and milk, poor circulation, constipation, etc. But grave affections like peri- 
tonitis are sometimes hidden by the psychosis, or, in other words, we may have 
to deal with a delirium secondary to some local inflammation or general sepsis. 

Prognosis. — While recovery is the rule, fatalities are by no means rare, in- 
cluding deaths from terminal dementia. In the fatal cases the cause of 
death is usually exhaustion, and this termination is said to be common in 
cases which have the appearance of acute delirium, due to some local or 
general affection. Many cases are so mild that recovery ensues after a good 
sleep. In some instances we see recurring insanity with lucid intervals, and a 
tendency to ultimate recovery. If a favorable termination does not result, the 
case becomes chronic, with one of three or more possible terminations: ultimate 
recover} 7 under proper management, terminal dementia, or paranoia, — the two 
latter incurable. A high pulse-rate is a bad prognostic sign with regard to early 
fatality. The special prognosis of late puerperal psychoses is good, although 
the duration is said to be longer than in the early forms. 

Insanity of Lactation. — Not much need be said of this type of maternity- 
insanity. Psychoses which develop after the puerperal period have received 
this designation. They may be classed, from the etiological standpoint, as 
psychoses of exhaustion, having the same exciting causes, symptoms, and prog- 



DISEASES OF THE NERVOUS SYSTEM. 839 

nosis as the late puerperal psychoses, from which they can with difficulty be 
separated. 

Treatment. — In cases due to sepsis the infection must first be carefully treated. 
(See page 815.) Sedatives will be needed for the maniacal symptoms, and during 
the whole course of the disease the patient must never be left alone, for fear that 
she may do herself injury. As in the insanity of pregnancy, the advice of an 
alienist should be sought. (Compare Insanity of Gestation, page 375.) 



XIII. SKIN DISEASES. 

i. Sudamina. — This is a trivial affection which appears in infectious diseases 
as well as in the lying-in period. Vesicles containing a clear, crystal-like fluid 
appear scattered over the abdomen. They are generally not accompanied by 
inflammation, break readily, and leave a lightly scaling surface. They owe 
their appearance to a retention of sweat, the ducts being blocked by swelling 
of the epidermis which surrounds their lumen. Treatment is hardly necessary, 
but an astringent lotion, such as calamine and zinc in lime-water, may hasten 
resolution. 

2. Eruptions of Septic Infection. — In addition to those diseases which are due 
to direct infection of the skin itself, such as impetigo and erysipelas, there are a 
number of eruptions caused by lodgment in the skin of pus organisms from 
internal foci. Their diagnosis is very materially aided by concomitant symp- 
toms, an infected uterus, the characteristic temperature movement, arthritis, 
endocarditis, or all the clinical evidences of pyemia. The cutaneous signs vary 
greatly. They may consist of an erythema only, or a patch of redness irregular 
in outline on which is seated a number of pustules in various stages of transforma- 
tion into crusts. The erythema may fade on pressure or it may not, owing to 
the presence of hemorrhage. Purpura may be the only sign. There is a septic 
pemphigus in which bullae occur on all the surfaces except the palms, soles, face, 
and mucous membranes. 



XIV. GENERAL DISEASES. 

The puerperal woman is quite as susceptible to the influences of the general 
diseases as her non-puerperal sister, if not more so. One must bear in mind, 
however, that all such diseases are modified somewhat by the peculiar con- 
ditions of the puerperal state, and also that there is the possibility in all 
instances of a mixed infection. These general diseases have already been 
considered in the section on Fever in the Puerperal Woman, page 745, Part VII. 



XV. SUDDEN DEATH IN THE PUERPERIUM. 

Sudden death during the puerperal period must naturally include all causes 
enumerated under the head of Sudden Death during Labor (page 728), since 
death may not occur until after delivery. But if very soon after the com- 
pletion of labor, should be ranked in the class with death during labor. There 
are also some cases in which the act of labor is not so likely to provoke death 
as is the puerperal state. Thus, after delivery a diabetic patient may pass 



840 



PATHOLOGICAL PUERPERIUM. 



into the condition of diabetic coma; a patient with contracted kidneys or tuber- 
culosis may develop cardiac paralysis, etc. Again, the mischief may be due 
primarily to the act of labor itself, death being deferred until the puerperal 
period. In hemorrhages of all kinds this happens from the profound anemia 
induced by the loss of blood. Air embolism is of more infrequent occurrence, 
but is also deserving of special study. 

Frequency.— Sudden death in the puerperal state is by no means rare. Porak 
was able to report before a meeting of the Paris Obstetrical and Gynecolog- 
ical Society * four cases which had occurred within a relatively short interval. 
The causes were as follows: chronic heart disease, profound anemia following 
hemorrhage, air embolus following an intrauterine injection, and embolism of 
the pulmonary artery. 

General Etiology. — Conditions of sufficient importance to require individual 

discussion are shock, heart 



VENA CAVA 



SPERMATIC 




OVARY 



Fig. 993. — -Aseptic Thrombosis of the Uterine and 
Para-uterine Veins in the Normal Puerperium. 



disease, embolism, air em- 
bolism. It is necessary to 
consider these conditions 
separately in order to note 
the various indications for 
treatment. 

1. Syncope and Shock. — 
Syncope is a natural termin- 
ation of fatal organic heart 
trouble, embolism, air em- 
bolism, etc. After exces- 
sive loss of blood a condi- 
tion of syncope is also a 
logical phenomenon. But 
we encounter fatal syncope 
at times in patients who 
have lost no blood, and who 
present at autopsy no evi- 
dence of embolism, throm- 
bosis, or air in the blood, 
and who have no valvular 
heart disease. Some of 
these women doubtless suf- 
fer from a certain amount 
In death from shock the fatal termin- 
in cardiac paralysis. The patient 



CERVIX 



of degeneration of the myocardium 
ation does not supervene so early as 
enters into a state of collapse with rapid and feeble pulse, cold and moist 
skin, pallor, etc.; while shock follows naturally from loss of blood, operative 
intervention, we also observe it in physiological labor in the highly sensitive 
woman. The mere emptying of the uterus may produce this condition, doubt- 
less from the sudden lowering of the intra-abdominal pressure. Treatment: 
The management of syncope and shock is practically the same in each affection. 
Stimulants, such as brandy, ether, strychnin, and camphor, and similar remedies 
hypodermic ally with brandy and ammonia by the mouth, are to be employed, 
with nitrite of amyl inhalations. The foot of the bed should be elevated and 
the body surrounded by dry heat. Oxygen may be administered. It must be 
remembered that syncope is not necessarily a dangerous condition, but may be 

* " Le Bulletin Medical," Dec. 14, 1898. 



SUDDEN DEATH IN THE PUERPERIUM. 841 

little more than an ordinary fainting attack with a tendency to spontaneous 
recovery. 

2. Pulmonary Embolism. — This affection may occur during any of the phases 
of maternity: pregnancy, parturition, the puerperium, and the post-puerperal 
period. Etiology: Pulmonary embolism in the course of pregnancy is due, 
doubtless, to detachment of a portion of a thrombus in a uterine sinus, which 
affection in turn is to be attributed to a partial detachment of the placenta, 
and is sometimes seen as a result of attempts to produce premature delivery. 
Embolism after delivery may also be attributed in part to a uterine 
thrombosis, but the development of a thrombotic state of the pelvic, iliac, 
and crural veins is doubtless the remote cause of most of the cases of pul- 
monary embolism occurring in the puerperium. In other words, the predis- 
posing causes of pulmonary embolism in the various phases of maternity are 
comprised under the head of the causes of maternity-thromboses. Exciting 
causes which determine the production of embolism from thrombosis are some- 
times evident. The phenomena of embolism have occasionally followed par- 
oxysms of coughing, the act of rising in the bed, and efforts at defecation. 
But such are not necessary for the detachment of a portion of a thrombus. The 
clot of blood may be extremely friable, and this is especially true in septic cases. 
Symptoms: Pulmonary embolism expresses itself clinically by well-marked 
types, depending on the degree of obstruction within the pulmonary circulation. 
In the fulminant or apoplectic type the patient immediately drops dead. In a 
less severe type there is a brief interval of irregular pulse, dilated pupils, and 
dyspnea before death supervenes. A third type, while fatal, may not destroy 
life for some hours. The symptoms begin with anxiety, a marked degree of 
dyspnea, and restlessness, the patient passing quickly into a state of collapse, with 
an icy feeling, and a vanishing pulse. The mode of death in these cases is acute 
pulmonary edema. The preceding types are necessarily fatal by reason of the 
large calibre or the number of the obstructed vessels. In a second class of cases 
the affection, while severe, is not necessarily fatal. The symptoms agree closely 
in character with those produced by shock. There are a cadaveric pallor, a 
pulse barely distinguishable, and extremities of icy coldness. In a small pro- 
portion of cases premonitory symptoms of embolism occur. Sudden diminution 
in the volume of a milk leg should be sufficient to awake anxiety in the mind 
of the medical attendant. One observer (von Herff) has had this warning in 
two of his personal cases. Other premonitions have been noted — pain in 
the left shoulder-joint, angina pectoris, etc. Diagnosis: The recognition of 
pulmonary embolism is often very difficult or for an inexperienced practitioner 
even impossible. Even experts may be deceived, and it is related that a 
specialist of immense experience in this field once diagnosticated pulmonary 
embolism as ruptured tubal pregnancy with fatal hemorrhage. The symptoms 
pointing to the lungs are not well defined, for if the embolism is sufficient for the 
production of dyspnea and cyanosis, the picture of collapse develops. If the 
patient is not destroyed quickly by the disease, the symptoms of hemorrhagic 
infarction develop which should be easy of recognition. Prognosis: The prognosis 
can be discussed only from the standpoint of the chances of ultimate survival 
after the patient weathers the first shock of the disease. (See Hemorrhagic 
Infarction.) Treatment: There is no treatment for the fulminant type of the 
affection. If the patient survives the first onset, she should be treated for the 
coincident shock by rest, hot applications, and cardiac stimulants. In order 
to prevent the deposition of fresh emboli in the lungs, absolute rest is indi- 
cated and should be continued for weeks. 



842 PATHOLOGICAL PUERPERIUM. 

3. Primary Thrombosis of the Pulmonary Arteries. — Embolism from fragments 
of coagttla is by no means the sole lesion of this sort encountered in connection 
with maternity, for primary thrombosis may develop in the arteries of the lungs 
in cases in which puerperal phlebitis and thrombus are absolutely non-existent. 
In past years the question of the relative frequency of primary and secondary 
thrombosis has been actively debated. Some have gone so far as to state, with 
Playfair, that the majority of cases are primary rather than secondary. A 
third variety of thrombus may be due to clotting in the right heart, a detached 
portion of the coagulum plugging the artery; but practically we may regard 
such a case as primary, restricting the term secondary to cases in which the 
parent thrombus forms in a pelvic vein. The consensus of opinion is that 
primary thrombosis of the pulmonary arteries during the puerperium is a rare 
occurrence, and that the great majority of cases of sudden death from obstruc- 
tion of the pulmonary arteries are due to embolism. Clinically there is no 
method by which primary and secondary cases may be differentiated. 

4. Air Embolism. — This accident, which may occur either during or after 
labor, is by no means as common as pulmonary embolism proper, but doubtless 
ranks as the next most frequent cause of sudden death in connection with 
maternity. Definition: Air embolism is simply a form of pulmonary embolism 
in which the blood-vessels are obstructed by air bubbles which have found their 
way into the circulation through the uterine veins. Etiology: For air embolism 
to occur there are required a number of factors acting in concert. Air must have 
entered the uterine cavity from without (or gas must have been formed within) ; 
the uterus must be uncontracted ; the uterine sinuses must be patulous; and, 
finally, a certain amount of air must have obtained access to the circulation, 
since the ingress of a small quantity may not give rise to embolism. For air to 
enter the uterine sinuses before delivery, the placenta would have to be detached 
prematurely to a greater or less extent. This accident has actually happened 
before labor in connection with attempts to induce premature delivery. In 
cases of this sort the relation of cause and effect is very apparent; since the air 
which is often injected with the water by a bulb syringe may pass directly 
into the circulation. Air may doubtless enter the birth tract from the 
difference in the pressure within and without the abdomen, its ingress being 
favored by a patulous condition of the vulva, such as exists immediately after 
delivery, and by all kinds of manual and instrumental intervention. The re- 
laxation of the uterus which follows a pain should also be enumerated among the 
possible factors in the aspiration of air by the uterus. The air which enters the 
circulation may not proceed from without, since it may be generated in the uterus 
as the result of the death and putrefaction of the fetus, and enter the veins 
only after removal of the latter with the placenta. The symptoms are entirely 
similar to those of pulmonary embolism in general. Treatment: As in the case 
of ordinary thrombotic embolism, the management consists in prophylaxis and 
in the treatment of the pulmonary lesion per se in case the patient survives. 
Prophylaxis consists in the greatest care in all procedures which might possibly 
introduce air into the vagina or uterus, such as the induction of labor, vaginal 
and uterine irrigations, and the introduction of the hand for various operations. 
The secret of the prophylaxis, aside from the foregoing, is a firm grasp upon 
the fundus and uterine body before and during all vaginal and uterine manipu- 
lations. 



PART EIGHT. 
The Physiology of the Newly Born. 



I. GENERAL PHENOMENA. Establishment of Respiration. Changes in the 
Fetal Circulation. Umbilical Stump and Ring. Temperature. Pulse. 
Meconium. Feces. Urine. Digestion. Liver. Heart. Blood. Weight. 
Signs of Normal Nutrition. Breasts. Shape of Head. Sutures and Fon- 
tanelles. 

II. HYGIENE AND MANAGEMENT OF THE NEWLY BORN. First Care. 
The Bath. Care of Cord. Dressing the Child. Infant Feeding. (1) Ma- 
ternal Nursing. (2) Wet=nurse. (3) Artificial Feeding. (4) Patented or 
Proprietary Foods. Open Air. Sleep. Bladder and Bowels. The Nursery. 
Environment. Weaning. 



I. GENERAL PHENOMENA. 

Establishment of Respiration. — Until the fetus has ended its stay in liter o 
and is finally expelled into the outer world, its lungs are normally in a condition 
of complete atelectasis. The first respiration, however, is accomplished as soon 
as the fetus has entered the external atmosphere. Notwithstanding the many 
theories advanced, respiration is probably not caused by any one agent 
alone, but by the combined influence of at least two important conditions 
affecting the respiratory center in the medulla oblongata. The first and most 
important is stimulation of the respiratory center through the nervous system, 
and, secondarily, stimulation of this center through changes in the fetal blood. 
For the sake of convenience we consider the latter first. Changes in the fetal 
blood are brought about by a shutting-off of the oxygen supplied to the fetus ; 
for the strong and tonic contraction of the uterus immediately following fetal 
expulsion constricts, if it does not entirely occlude, the placental blood-vessels 
which have carried on intrauterine respiration. As a result of this, the supply 
of oxygen through the umbilical vein, which has furnished the fetus an abun- 
dance, is cut off. Following this stoppage a proportionately larger amount of car- 
bonic acid accumulates in the fetal circulation, as, for the same reason that the 
oxygen supply is lost, carbonic acid gas absorption by the placenta is also shut 
off. Carbonic acid gas greatly stimulates the center of respiration and respiratory 
action is established. The cause is occasionally illustrated as acting singly by the 
efforts of the fetus to respire before birth. The fetus leaves a liquid cushion with 
a temperature of qq° F. and quickly passes into the air of the lying-in room, usually 
at a temperature of 70 F., or 29 F. lower. This change produces an irritation 
of the skin, the shock of which is alone sufficient to cause a reflex action of the 
muscles, and a stimulation of the respiratory center. This fact is illustrated 
by our ability to induce respiratory effort in cases of suspended respiration in the 
newly born by the skin irritation caused when we immerse an infant alternately 
in hot and cold water, after the accumulation of carbonic acid gas in the blood 
fails to stimulate the respiratory center. It is easy to conceive of this mechanical 
irritation being alone sufficient to produce respiration, and therefore that this is 
the first great cause. With the first respiration the muscles both of ordinary 
and extraordinary respiration are brought into action, as shown by the lusty cry 
usually uttered at the moment of birth. By this too, the chest-walls, before 
unexpanded,* expand and remain so; the diaphragm is drawn up, the muscles 
of the nose and throat become active, and the physiological function of respira- 
tion is thoroughly established. The rate of respiration at birth varies physio- 
logically between 40 and 45, being a little more frequent in females than in males, 
as in after life, and a little less frequent in large robust infants than in weakly 
ones. The breathing in the infant is almost entirely abdominal, as the dia- 
phragm is the chief muscle causing it, the chest-walls and intercostal muscles 
taking very little part after the first few respirations, until later in life. Auscul- 

* According to Ballantyne, rhythmic movements of the thorax occur in utero. This 
abortive activity may be due to a precocious sction of the respiratory center. 

845 



846 THE PHYSIOLOGY OF THE NEWLY BORN. 

tation of the newly born reveals the presence of fine crepitant rales as the lungs 
expand. 

Changes in the Fetal Circulation. — Concomitant with the establishment of 
the first respiratory action, there occurs a change in the fetal circulation, as the 
oxygenation is no longer carried on through the placental circulation. This is 
now accomplished by pulmonary respiration in the infant. As the placenta is 
now useless, the functions of the omphalic vessels no longer exist, and the circu- 
lation connected with them ceases. In order clearly to understand these changes , 
it is important that the fetal circulation should be thoroughly understood. (See 
page 79.) Coincident with the first respiration the blood is diverted from the 
umbilical vessels, and is at once, — by aspiration, as it were, — following the draw- 
ing up of the diaphragm and expansion of the chest walls, carried through the 
pulmonary arteries and distributed by its capillary terminals to the vessels of the 
lungs. By this sudden change in the chief fetal blood-currents, equally important 
changes occur in the circulatory apparatus itself. The abdominal continuations 
of the umbilical vessels close and by thrombosis and atrophy become organized 
into strong, hard, fibrous cords. There being no propelling force of blood through 
the ductus arteriosus, it also closes. The blood, instead of being directed through 
the foramen ovale by the Eustachian valve, now passes into the right ventricle, 
and hence the usefulness of the valve and foramen is lost, the foramen closes, and 
the valve contracts. From the right ventricle the blood is forced into the pul- 
monary artery, and as there is no longer excessive pressure in it — as the capillary 
terminals in the lung are open — there is not the tendency of the blood to pass 
on into the aorta through the ductus arteriosus, the current to the lungs being 
no longer dammed back upon the pulmonary artery and this duct. The duct 
therefore collapses or contracts. By thrombosis here also organization begins, 
and in later life the duct is distinguishable only as a round cord. The blood is 
both forced and aspirated into the lungs through the pulmonary artery. From 
the lungs it is returned reoxygenated to the left auricle through the pulmonary 
veins, and is then ready to furnish nourishment to the entire economy. It 
is therefore pumped into the left ventricle through the auriculo-ventricular 
orifice, and thence into the great blood-main of the body, the aorta, whence it 
is distributed through the branches, terminals, and capillaries. That these 
changes are anticipated during fetal life is shown by the fact that the ductus 
arteriosus and ductus venosus do not increase in size in the same ratio as the 
aorta, venae cavae, etc. 

Umbilical Stump and Ring. — A line of demarcation appears at the base of the 
umbilical stump at the end of twenty-four hours; necrosis of the covering of the 
cord and mummification of the jelly of Wharton follow (Figs. 994, 995, 996). 
The remains of the umbilical vein and arteries are gradually destroyed. The 
line of demarcation deepens and the stump falls at about the fourth day (Fig. 
996). Retraction of the granulating remnant of stump within the umbilical ring 
follows and is apparently complete about the tenth day (Fig. 997). The umbil- 
ical ring is merely the opening in the abdominal wall around which the cord 
substance is fastened and through which the umbilical vessels pass. There is 
a distinct line of division from the cord substance, about a fourth to a third of 
an inch from the abdominal wall, which pouts to form the ring. This line, 
which also marks the point of separation of the cord, is distinguished from 
the soft, gelatinous, pearly- white substance of the placental end of the cord as 
a red ring formed of a network of capillary blood-vessels covered by a very 
thin, delicate skin. The ring, after the falling off of the cord on the fourth or 
fifth day,- leaves a healthy granulating surface which soon cicatrizes (Fig. 997). 




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GENERAL PHENOMENA. 847 

Owing to this cicatricial contraction and to the shortening of the intra- 
abdominal remains of the umbilical vessels, the ring sinks into the abdominal 
wall to the depth of a fourth or a third of an inch as a small, puckered scar, 
and remains thus through life as the navel or umbilicus. This is always wider 
and deeper in the female than in the male. 

Temperature. — At birth the fetal temperature varies slightly, averaging 
about 99.5°toioo.5°F. This is about 0.5 to i° higher than the vaginal tempera- 
ture of the mother. It is what would be expected, as the fetus has been en- 
compassed in the uterus by a liquid cushion at the internal maternal temperature 
of 99 F., which can take up very little of the temperature of the fetus, as 
radiation from this liquid must be slight. Hence the metabolic changes occur- 
ring in the growing fetus are sufficient to keep its temperature about i° F. higher 
than the maternal temperature. Soon after birth the temperature has fallen 
about i.8°, but again reaches the normal infant temperature of 99. 4 F. in about 
twenty-four hours. The temperature varies irregularly during the first few 
weeks of life, being elevated sometimes even 0.5 by prolonged and vigorous cry- 
ing, and dropping o.6° to i° during sleep. 

Pulse. — The pulse-rate in the newly born varies between 130 and 140 per 
minute, depending upon the activity and robustness of the child, also being 
slightly faster in a healthy female than in a male. As has been stated, the respi- 
rations are much more rapid and shallower in the infant than in later life, and 
the temperature is higher. An increased pulse-rate would consequently result. 
This rate varies greatly physiologically, being increased from 20 to 30 beats per 
minute by muscular activity from any cause, such as crying or being raised 
from the recumbent to the upright posture. Great excitement sometimes 
increases its frequency and also its force. It may in perfect health, especially 
when very rapid, be very irregular physiologically. As throughout life, it 
varies in proportion to the respirations and temperature, though much more 
irregularly. 

Meconium ; Feces. — A study of the stools in infancy is valuable not only on 
account of the information it gives concerning the alimentary processes, but also 
because it determines in a great degree the necessary strength and quantity of the 
infant's food. Besides, it aids us in determining the nature of many of the 
disturbances so frequent at that period of life. The newly born infant passes 
stools greenish-black in color, known as meconium, composed of mucus, bile, 
vernix caseosa, epithelium, hair, fat crystals, phosphates, and bacteria. After the 
fourth or fifth day the stools of a baby fed upon milk alone, whether from breast 
or bottle, should be yellowish, pasty in consistency, of acid reaction, and not 
disagreeable in odor. The color is due to bilirubin and the reaction to lactic 
acid, the source of which is the milk sugar. Mucus and epithelium are always 
present. Miller, who has carefully studied the various micro-organisms in the 
mouth, found that the majority of them could again be located in the intestinal 
canal. In the feces, two germs, Bacterium lactis aerogenes and Bacterium coli 
commune, are the most important. In the first two weeks the stools number 
from three to six each day; after the first month they vary from one to three 
daily — the average being two each day. Later in infancy, when other articles 
are added to the milk diet, the stools, while remaining soft and watery, become 
darker in color and contain a greater variety of bacteria. The gases present are 
hydrogen (H) and carbon dioxide (C0 2 ), the adult odor being acquired later, 
due to the presence of hydrogen sulphide (H 2 S). The bulk of the stool is com- 
posed of about 85 per cent, water, and fat varying in amount from 2 to 4 per 
cent. Pathologically the stools may assume one of a variety of colors and con- 



848 THE PHYSIOLOGY OF THE NEWLY BORN. 

tain any of a long list of materials. Green stools are of very frequent occurrence. 
When very acid or thin, they often cause irritation of the buttocks and are 
accompanied by colic. The green color is due to pre-formed bilirubin. These 
stools usually contain more or less undigested casein and fatty acids. Stools 
varying in color from pale greenish-yellow in the early stages to grass green later, 
are seen in cases of acute intestinal indigestion, the result of improper feeding. 
An excess of sugar causes thin, acid, green stools. Bismuth, tannic acid, and 
the iron salts color the stools from deep brown to black. Blood gives the char- 
acteristic tarry stool when the blood is admixed higher up in the intestinal 
canal; when lower down, it is brighter red in color. An excess of mucus indi- 
cates some inflammatory condition of the large intestine. Light or light gray 
stools of a pasty consistency, or in dry balls, contain an excess of fat and are 
usually offensive in odor. When proteids are in excess or too much food is 
given at a time, curds appear in the stools, sometimes with diarrhea, but more 
often with constipation and colic. Curds are especially liable to occur in infants 
fed upon cow's milk, particularly when sterilized. 

Urine. — As a rule, almost immediately after birth the infant voids urine 
at or just before the time it passes meconium. It is of 
a slightly urinous odor, aqueous in color, markedly acid, 
specific gravity 1004 to 10 10, containing an unusual 
amount of albumin in 33 per cent, of cases, a 'few 
granular and numerous hyaline casts, an . inordinate 
amount of uric acid, and frequently some sugar. These 
Fl S;?T 98 T7r.VS^ B t£^J are a11 characteristics of the urine of the newlv born. 
Extracted with In a short time, varying from three days to three months, 

Thumb-forceps from these change. In about three days the specific grav- 

an Infant Two Days -. A , c ,-, « . j- 

Old. The tooth in- ^Y drops to from 1003 to 1006, the albumin disappears 

terfered with nursing with the casts, epithelium, and excessive mucus ob- 

by causing an erosion ser ved at first. The urine is passed frequently during 

of the nipple. — (Case , , . , f j.i j ' • 1 

at the Emergency Hos- tne waking hours, but less frequently during sleep. 

pital.) Normal urine should not stain the napkin. 

Digestion. — As milk contains all the nutritive prin- 
ciples found in the various foods ingested by the adult, we would expect to find 
in the infant the numerous digestive agents necessary in adult life, and such is 
the case, though they are present in smaller quantities. Besides these, there is 
in the stomach, in proportionately larger quantity than in adults, a ferment 
especially adapted to the infant food, known as the rennet ferment, the 
action of which is to curdle milk on its entrance into the stomach. As the 
milk rapidly passes through the mouth during nursing, there is very little 
use for saliva, with its power of changing starch into sugar. The milk 
having been sucked into the mouth, it is swallowed at once. Owing to the 
small amount of saliva, and consequently of ptyalin, and also of the deficiency 
of the pancreatic secretion, provision for the digestion of starches is lacking 
in young children. The practical application of this fact will be noted in con- 
nection with infant feeding. With the above exception infantile digestion is 
accomplished in the usual way. It is aided, however, by the presence of bac- 
teria in the alimentary canal. As soon as milk enters the stomach the rennet 
ferment causes ^ a soft flocculent curd to be formed. This is the chief part of 
gastric digestion in the infant, as the pepsin and hydrochloric acid begin to 
digest this curd only when it is passed on into the intestine. It will be remem- 
bered in this connection that in the newly born the stomach serves more the 




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849 




Fig. 9Q9. — Two Middle 
Lower Incisors. Ap- 
pear third to tenth 
month; average, 
seventh month. 



part of a reservoir than of a digestive organ. The proteids have been partially 
changed into peptones and some absorption has taken place. Having been 
poured into the intestinal tract, the milk is here brought in contact with the pan- 
creatic secretion, which contains all the ferments necessary for converting more 
completely the proteids into peptones, for emulsifying fats, and for changing 
starch into sugar. Here, too, it is brought in contact with the bile from the 
liver, which further helps to emulsify the fats. These fats are principally 
absorbed from the small intestine, as are also the peptones, salts, and sugar; the 
glands of the large intestine are as yet imperfectly developed, hence its absorb- 
ing power is slight. 

Liver. — At birth it is well to remember the very large size of the liver in 
proportion to the body, it being about one-thirtieth 
the entire body- weight. This is readily understood 
when it is remembered that the liver and the head are 
nourished in fetal life by the practically pure freshly 
oxygenated blood, and consequently these parts are well 
developed. Immediately after birth the secretion of 
bile is lessened because of the diminished blood-supply to 
the liver. Pressure upon the hepatic veins is lessened. 
During exfoliation of the stump of the cord the capsule 
of Glisson may become swollen. 

Heart. — At birth the heart is relatively larger in com- 
parison with the body -weight than at any other time of 
life. The walls of the two ventricles are found to be 
nearly of the same thickness, for the two sides of the 
heart have been doing about the same amount of work. 
At birth the work thrown upon the left ventricle 
is greatly increased, in comparison with the right, 
hence the left increases in thickness more rapidly, and 
later in life we find that it has reached the proportion 
of about 2 : i instead of about 6 : 7 as at birth. The 
heart's action is much more frequent at birth than 
later, being also more frequent and less regular in 
females than in males. Its position is not so oblique as 
in the adult. The apex impulse is farther to the left 
than later in life, and usually for the first few days is 
just outside the mammary line in the fourth intercostal 
space. The sounds are much louder comparatively 
than in adult life, owing to the thinness of the chest- 
walls and the greater area of cardiac dulness — the lung 
not overlapping the heart to so great an extent. 

Blood. — At birth the proportionate amount of blood 
is less than in the adult, averaging about -^ the body-weight, while later in life it 
is about xV- This varies in the newly born, depending largely upon the time 
when the umbilical cord is tied. In immediate ligation the weight may be 
only T V, while if ligation is postponed until cessation of pulsation in the cord it 
may be even greater proportionately than in the adult, often being as high as 
tV the body-weight. While the specific gravity and hemoglobin are higher, and 
the proportionate number of red and white cells is greater, and the proportion 
of white cells to red is also increased, — about 1 : 160, — the blood is thinner, 
more watery, contains less fibrin, and therefore does not coagulate or clot so 
readily as adult blood. There is also a much greater variation in the size and 
54 




Fig. iooo. — Four Upper 
Incisors. Appear 
ninth to sixteenth 
month. 




Fig 



)i. — Order of 
the Eruption of the 
Eight Incisors (Milk 
Teeth). 



850 THE PHYSIOLOGY OF THE NEWLY BORN. 

appearance of the blood-corpuscles, as the blood-glands continue to form new 
cells in greater quantities for about three days. 

Weight. — At full term an average fetus weighs about 7.3 pounds. The 
weight varies largely, as would be expected, depending on numerous influences 
which it is well to mention: (1) Depending upon the parents, (a) The size of 
the parents seems to influence somewhat the size of the infant; infants born of 
parents of large stature are, on an average, larger than those whose parents are 
small, (b) Strong, healthy parents may also expect larger children than do those 
in feeble health, (c) The age of the mother seems to influence the size of the 
infant, — women between twenty-four and thirty-four bearing the largest children, 
as this is the prime of motherhood, (d) Parity. The offspring of primiparae 
average less in size and weight than those of multiparae. Also, each fetus seems 
to weigh a little more than the preceding one when sufficient time elapses be- 
tween births, (e) Frequency of child-birth greatly influences the size of the 
fetus, as in pregnancies rapidly following one another each succeeding child 
is less robust. (2) Sex. Males average a greater weight than females. There 
is for three days a continuous loss in weight, due partly to the frequent 
discharge of urine and feces, but largely to the excess of tissue waste over 
tissue reconstruction. This averages about 11 per cent, of the body -weight. 
The weight is gradually regained, however, from the third day on, and by the 
tenth day has reached the weight at birth. This steady increase should there- 
after continue uninterruptedly in a healthy child. 

Signs of Normal Nutrition. — The end of the first week of life generally finds 
an infant at the weight accredited to it at birth; the slight loss attendant upon 
the elaboration of the mother's milk during the first three or four days is made 
up at the end of the first week. After this period the weight of a properly 
developing infant will increase from 6 to 8 ounces each week, or, roughly speak- 
ing, an ounce a day for the first two or three months. At the end of the fifth or 
sixth week this gain is slightly lessened, but it is steady. Taking seven pounds 
as the average weight of an infant at birth, it should weigh fourteen pounds at 
the end of the first five months and twenty-one pounds at the end of the first 
year. 

TABLE SHOWING THE GAIN IN A HEALTHY INFANT FED AT THE BREAST. 

Normal weight at birth, 7 lbs. Gain at end of first week, none. 

Weight when 2 weeks old, 7 lbs. 6 oz. " 2d " 6 oz. 

3 " "7 lbs. 14 oz. " 3d " 8 oz. 

" 4 " 8 lbs. 6 oz. " 4th " 6 oz. 

In a breast-fed infant when the weight does not increase, the milk should 
be examined to determine which ingredient is at fault. Any failure to gain 
steadily in a baby fed upon modified milk warrants a change either in the quan- 
tity or the strength of its food. Besides the 'gain in weight, which emphasizes 
more strongly than any other factor that the baby is thriving, its general con- 
dition, whether it is comfortable, its sleep quiet and sufficient, the stools, with 
their number, color, and consistency, should be taken into consideration. It 
is not a rapid but a steady gain in weight which is all-important. 

Breasts. — At birth the breasts of the infant are sometimes found to be com- 
paratively large, swollen, and secreting. This secretion is greatest usually at 
the end of the first or beginning of the second week. At this time the glands 
are increased in size, red, with elevation of temperature, rather hard, and very 
sensitive. The vessels are turgid and the whole merely presents a picture of a 
functionating gland (Fig. 985). Normally this secretion continues only for 
about two weeks, but may be found much later, the secretion itself being about 



HYGIENE AND MANAGEMENT OF THE NEWLY BORN. 851 

the same in appearance as the mother's milk. The amount of secretion is the 
same in the two sexes, it being merely a physiological gland activity. No harm 
commonly results, but all manipulation or attempts to express secretion should 
be forbidden, since they may result in the development of an abscess. (See Part 
IX.) 

Shape of Head. — After moderate moulding during labor, the head usually 
resumes its normal shape in four or five days. In the excessive moulding of per- 
sistent occipito-posterior positions, in temporary mento-posterior positions, and 
in presentation of the anterior parietal bones (Naegele's obliquity) a return to the 
normal contour may be delayed as long as two weeks or more. I have tracings 
of the head taken at birth in the first and second of the above positions, and also 
one and two weeks after delivery, showing the tardy return to the normal. The 
caput succedaneum rapidly disappears even when extensive. Change in shape 
largely due to a cephalohematoma may persist for two or three weeks, or until 
the blood-clot is absorbed. (See Part IX.) 

Sutures and Fontanelles. — The edges of the cranial bones are normally in 
apposition at birth. Separation is commonly due to prematurity, syphilis, or 
rachitis. Ossification does not usually occur until the end of the sixth month 
or later. The posterior fontanelle is usually closed about the end of the second 
month and the anterior about the eighteenth. 

Post-mortem Observations. — These in the infant should include (i) the rela- 
tively large size of the thymus gland and heart; (2) whether the thymus ob- 
structs the trachea; (3) whether the lungs are inflated and overlap the heart; 
(4) the relatively large size of the bladder, sigmoid flexure, appendix, and 
liver; (5) infection of the hypogastric arteries from a septic umbilical ring. 



II. HYGIENE AND MANAGEMENT OF THE NEWLY BORN. 

First Care of the Infant. — After the cord has been tied and cut and the eyes 
have been washed with a solution of boric acid, the baby should be wrapped 
in a soft, warm piece of flannel, laid in some convenient place out of harm's 
way, and covered with a shawl or other covering, taking care to allow sufficient 
breathing space. Here it mav remain till the mother has received proper 
attention. It should occasionally be noted that the respirations are regular 
and that there is no oozing from the cord (page 541). 

The Bath.- — After making the mother comfortable the nurse may attend to 
bathing the child. The necessary articles have been provided and stand ready 
for use, in winter near a fire or register. They consist of a small tub or bowl 
of water at 95 to ioo° F., a soft rag, and a warm, soft towel. The nurse should 
wear a flannel apron or may have a flannel apron or petticoat spread over 
her lap. The vernix caseosa is miscible with sweet oil and is best removed 
by a free use of oil. The infant is then gently sponged with a soft cloth and 
tepid water. Only a small part of the body is bathed at a time, the rest being 
kept covered. The bathing is done in the warmest part of the room, before 
the stove, register, or best an open fire. All manipulations should be gentle, 
and feeble or premature children should not be washed, the vernix being cau- 
tiously removed, care being taken that the surface does not become chilled. It is 
better not to give a tub-bath till the tenth day, as it is something of a shock, 
and its repetition tends to prevent healing and desiccation of the umbilicus 
and mav result in infection. The usual tendency is toward too much bathing, 



852 THE PHYSIOLOGY OF THE NEWLY BORN. 

scrubbing, and exposure. During the first ten days the child should be cleansed 
daily as above described. Soap should be used moderately, and chiefly about 
the 'genitals and axillae. Fine castile soap is to be preferred. Powders are 
unnecessary except about the genitals and flexures of the joints and folds of 
skin; powdered starch, talc, or lycopodium may be used. 

Care of Cord. — The cord should be dusted with a non-toxic antiseptic or 
aseptic powder, as pulverized boric acid or sterile starch, wrapped in borated 
absorbent cotton, and kept as dry as possible. Since septic infection may occur 
at the umbilicus, the nurse should carefully disinfect her hands before touching 
this region. After separation of the cord the umbilicus should be kept per- 
fectly clean, but not washed more than necessary, and should be dusted with 
powdered boric acid or sterile starch. 

Dressing the Child. — The infant's clothing should be warm, loose, easily re- 
moved, and not irritating. The band is unnecessary, and when pinned as tightly 

as is often done, is decidedly injurious by interfering 
with respiration and leading to defective develop- 
ment of the abdominal wall. If used, it should be 
applied loosely, should be of flannel or knitted wool, 
and should extend from the pubis to the axillary 
region. The undershirt should be of soft flannel, 
with high neck and long sleeves, and buttoned all 
the way so that it can easily be removed. The 
dress should be of flannel, twenty-five inches from 
neck to hem, opening in front; over which may 
be worn a muslin slip, opened behind if desired. 

Long woolen socks should be added and the baby 
Fig. 1002. — Diagram show- -, -, -,->.• -, , -, -, r i j a. i- 

ing Sterile Gauze Dress- 1S dressed. Diapers should be of old soft linen or 

ing for Umbilical Cord. cotton diapering; they should not be hemmed, as 

this makes little ridges. They should be rough 
dried, as ironing makes them hard and less absorbent. They should be 
changed as soon as wet and not used again without washing. If used without 
washing, they cause chafing. Infants are, as a rule, too warmly clad in 
summer. The amount and quality of the clothing should be changed accord- 
ing to temperature, so that sudden chilling of the surface may be avoided. 
In cold weather it is necessary to protect the baby thoroughly, but if the 
house is kept at the average temperature of American homes, a more decided 
difference than usual should be made between the indoor and outdoor garments. 



INFANT FEEDING. 

a/ i. Maternal Nursing. — After delivery is completed and the abdominal binder 
is applied the patient must be allowed a number of hours of sleep, after 
which the child may be placed at the breast. The suction exerted by the 
infant at this time favors the contraction of the uterus, assists in the formation 
of the first milk, and abstracts the colostrum from the breasts. The latter 
substance is supposed to exert a favorable influence on the digestive apparatus 
of the infant. Whenever possible the mother should nurse her own child, 
since the nutriment thus supplied is unquestionably the most natural and 
wholesome food in the earliest period of life, and it can be proved that involution 
is more satisfactory in women who nurse their children. Unfortunately, this 
is not always possible for a variety of reasons, some of which are due to 




HYGIENE AND MANAGEMENT OF THE NEWLY BORN. 



853 



the strain of modern civilization and abnormal environment, others of which 
depend upon deformity or disease on the part of the mother or child. Some 
of the most important conditions are, on the part of the mother, syphilis, phthisis, 
mammary abscess, marked anemia, and depressed or absent nipples; and, on 
the part of the child, harelip. 

The secretion of milk is usually established in the second twenty-four-hour 
period after delivery, and it is not necessary to supply any form of nutriment 
to the child before the expiration of that period, except what it gets from the 
breast. Warm water, however, should be freely administered. It is a mistake 
to give milk and water, sugar- water, or any artificial food during this period; 
though if proper milk secretion is not established by the beginning of the third 
day, it may be necessary to begin artificial feeding at least temporarily. Even 
in the first two days of life it is practicable to feed infants with a modified 
milk containing a very low percentage of proteids, about 0.25 to 0.5 per cent. 
Such infants do not lose weight, as is often the case when all food is withheld 
for this time. (See Treatment 
of Prematurity, page 868.) 
When the flow of milk is prop- 
erly established, the child must 
be trained to nurse at regular 
intervals, and it must not be 
put to the breast every time it 
cries. The proper intervals vary 
somewhat according to the age 
of the child, and may be roughly 
estimated as follows : Up to the 
age of six weeks, every two 
hours between 6 a.m. and 10 
p.m., and one feeding between 
10 p.m. and 6 a.m.; from six 
weeks to four months, every 
two and a half hours, with one 
night feeding; from four to 
nine or ten months, every three 
hours, without any feeding be- 
tween 10 p.m. and 6 a.m. Water 
may be given occasionally be- 
tween feedings. Each breast must get its share of use, and it is best 
alternate regularly. The child should be allowed to nurse for 
twenty minutes and no longer 




Fig. 1003. — Baby Scales. 



to 
fifteen or 
Irregularity in feeding is a prolific cause of 
indigestion and flatulence in the infant, and is often the cause of maceration 
of the nipple, besides being a great annoyance to the mother. If the child 
shows an inclination to nurse longer than twenty minutes, it indicates that 
there is a deficient supply of milk in the breast. Failure to nurse satisfac- 
torily may be caused by placing the child in such a position that it cannot 
secure a proper hold on the breast and has to seize the nipple obliquely, or 
the child's nose may be pressed so closely against the breast that breathing 
may be interfered with and thus satisfactory nursing becomes impossible. 
These are matters very easily regulated, and though apparently insignificant, 
should never be neglected. The physician should satisfy himself by actual 
observation that all is being done properly, since carelessness and lack of 
knowledge are all too common. 



854 



THE PHYSIOLOGY OF THE NEWLY BORN 



The average composition of average normal human milk is put down thus : fat, 
4.00; sugar, 7.00; proteids, 1.50; alkaline reaction and no bacteria. Variations 
occur frequently, but between moderate limits are not significant and do not dis- 
turb the infant's digestion. The quantity of milk may be increased by attention 
to the general health of the mother and by allowing plenty of fluids. Cathartics 
and curtailment of fluids have the opposite effect. Malt preparations, milk, 
and gruel seem to have a special faculty of increasing the milk-supply. The 
quality of the milk may vary from over-rich to bad. Too much rich food, 
improper habits of life, and insufficient exercise will cause the milk to contain 
too high a proportion of solid ingredients, the chief disturber of the infantile 
digestion being the increase of proteids. The remedy for the condition is 
obvious. A poor milk usually contains too much proteid and a subnormal 
amount of sugar and fat, while a bad milk accentuates this disproportion. 
Overwork and improper diet will cause the milk to be poor, while the causes 
of the production of a bad milk are usually put down as 
neurotic. 

2. Wet-nurse. — The best substitute for the milk of 
the mother is the milk of a healthy woman who is 
nursing a child of about the same age as the infant she 
is to feed. To be a desirable wet-nurse, a woman should, 
in addition to having a child of about the same age as 
the child she is to nurse, be free from any communicable 
disease, such as tuberculosis, syphilis, or gonorrhea; she 
should have a good quantity of milk and the nipples 
should be normal in development and general condition. 
If possible, her child should be examined for evidences 
of syphilis, which when it occurs is sometimes more 
evident in the child than in the mother. Until the 
character of the nurse is proved, she should be watched 
while she is nursing the child, and if all goes well, the 
result will be as good as if the child were nursed by its 
mother. The diet of the nurse will, of course, require 
supervision, and in many cases it will be necessary to 
guard against overindulgence in malt liquors. There 
is no more difficult or thankless task than the procuring 
and supervision of a wet-nurse, and she has been defined 
by some one "as one part cow and nine parts devil." 
— This must be resorted to when the mother cannot nurse 
It is only when maternal nursing is 




Fig. 1004. — Materna 
Graduate Glass for 
Artificial Infant 
Feeding. 



3. Artificial Feeding. 

her child and a wet-nurse is not available, 
impossible or when it presents conditions which are unsuitable, such as when the 
milk is unreliable in quantity and too poor in quality properly to nourish the child, 
that artificial feeding should be resorted to. Breast-milk practically does not 
change its composition during a normal lactation, but it has been observed 
that infants cannot take so rich an artificial food as a natural one, and it is 
necessary to alter the proportion of some ingredient in preparing the artificial 
food. In certain cases the woman can supply a portion of the milk required 
by the infant and the deficiency must be made up by the use of a modified 
cow's milk. The intervals between feedings must be just as carefully regulated 
as in the case of nursing. It is also necessary to regulate the amount of food 
given at a time. A good rule is at the age of one week to give one ounce each 
time; at four weeks, 2I ounces; at three months, 4 ounces; at six months, 6 
ounces; and gradually to increase to 8 ounces, which is as much food as a child 



HYGIENE AND MANAGEMENT OF THE NEWLY BORN. 855 

should ever take at a time until weaned. The best results are obtained by 
making certain modifications in the ingredients of cow's milk to make it conform 
to human milk, and by starting with a very low proportion of fat and proteid, 
gradually increasing as the child approaches eight or nine months. The various 
strengths which seem to give the most satisfactory results at various ages are 
thus tabulated. The ingredients should be, in the first months of life: 

Fat. Sugar. Proteid. 

First week 2 . 00 500 0.50 

Second " 3. 00 6.00 °-75 

First month 4.00 7.00 1 . 00 

Second " 4 . 00 7 . 00 1 . 50 

Fourth " 4.00 7.00 2.00 

Sixth " 4 .00 7 .00 2 . 50 

Eighth ' 4.00 7.00 2 -75 

A properly constituted artificial food must contain only substances normally 
found in milk; it must be alkaline and sterile,* easily obtained, and its prepara- 
tion not too complicated. It must as nearly as possible be of the composition 
of human milk and susceptible of modification to suit individual cases. Cow's 
milk is the most easily obtainable basis for modification. According to Meigs, 
the comparative average composition of human and cow's milk is: 

Human Milk. Cow's Milk. 

Water 87.16 87 . 10 

Fat, 4.28 4.20 

Casein, 1.04 - 3 . 2 5 

Sugar, 7-40 5 . 00 

Salts, 0.10 0.52 

Human milk is also alkaline and practically sterile, while cow's milk as it reaches 
the consumer is usually slightly acid and always contains bacteria. Other 
analyses give somewhat different results, but these may be taken as an average. 
Human milk differs in two important respects — it contains more sugar and 
markedly less proteid. The proteids of human milk are casein and lactalbumin, 
both not in solution but suspension, and capable of making a finely divided 
curd more readily digestible than that of cow's milk. Further, the proteid 
matter is of a different character. Fats are about the same. In some respects it 
is easy to make cow's milk conform to the standard. A sufficient amount of milk- 
sugar added makes this ingredient satisfactory, and the acidity can be corrected 
by the addition of lime-water. Brush and Jacobi maintain that cane-sugar is the 
ideal addition. Milk-sugar is rapidly changed into lactic acid. Sometimes it is 
borne well, at others not, because of the excess of lactic acid, which interferes with 
digestion. The presence of harmful bacteria must be prevented by care and 
cleanliness and their action may be overcome by sterilization. The regulation of 
fats and proteids is not so easy. A simple way is to dilute with water till the pro- 
teid is properly reduced and then add cream. When a fair trial has been given 
water as a diluent and vomiting of tough curds or their presence in the stools 
persists, barley or oatmeal water should be used to "split" the curds. Diluting 
milk with water does not prevent the formation of tough curds, but diluting 

* Concerning the advisability of sterilization, it may be well to mention that children 
do not thrive well upon milk which has been subjected to a temperature of 212 F. for 
an hour and a half. The casein is made more firm and certain changes occur in the fat 
which tend to constipation. In the summer, when diarrheal diseases are prevalent, it 
may be of advantage to resort to sterilization when clean, fresh milk cannot be procured. 
Human milk obtained from 73 breasts of 64 nursing women, examined by Honigman with 
all aseptic precautions, contained Staphylococcus aureus or albus in all but four cases, 
the number varying from 1 to 9000 in a cubic millimeter, which seems to confirm the 
belief that micro-organisms are not necessarily prejudicial to health. 



856 THE PHYSIOLOGY OF THE NEWLY BORN. 

with gruels does prevent the hardening of the curds, as is proved experi- 
mentally and clinically. Barley water is used to prevent the formation of large 
curds by mechanical separation of the milk globules, but this is not always 
a good plan, because before the third month of life starch digestion practically 
does not exist on account of the lack of development of the pancreas. Whatever 
modified milk is used may be sterilized or pasteurized, if necessary, by keeping it 
at a temperature of 157 to 168 F. for twenty minutes. When boiled, the mixture 
is apt to cause constipation. The preparation of a modified milk can be under- 
taken without great trouble at home, but in the larger cities the matter may 
be left to certain laboratories, which may be depended upon to furnish an 
accurately modified food according to directions. The cost is considerable, how- 
ever, and among the poor the plan is not feasible. In this case home modi- 
fication is necessary. The principle on which milk is modified depends on the 
separation of the fatty portions in the cream, by standing or by centrifugal- 
ization ; by these methods the cream and fats are separated to one part of the 
mass while the proteids and milk-sugar remain equally distributed in the 
whole. By regulating the time of standing and selecting certain portions of 
the milk mass it is not difficult to select a specimen which contains any de- 
sired strength of cream. For example, a specimen standing six hours gives: 

Upper £, fat, 12.0 %; sugar, 4.4%; proteids, 3.78%. 

Upper i " 10.0%; •' 4.5%; 3-85%. 

Lower i, " 0.25%; " 4.5%; " 3-%5%> 

Longer standing increases the percentage of fats in the upper fifth. 

In preparing modified milk it is necessary to work on a percentage basis entirely if 
good results are desired. Bauer * has given a simple and on the whole satisfactory method 
of calculating the composition for any desired modification of milk for infants' use. 

Q = the quantity in ounces for twenty-four hours. F = the desired percentage of fat. 
S = the desired percentage of sugar. P = the desired percentage of proteids. 
A = the desired percentage of alkalinity. C = cream; M = milk; L.W. = lime- 
water. 

Cream, 8 x (F — p) 

Percentage of fat in cream — 4 

Milk Q^- p -c 

4 

Lime-water, -A_ x o. 

100 
Water, q _ (c - m - l.w.). 

Dry milk-sugar, (a — P) x Q 

100 

Example: If 40 ounces of a mixture containing 4 per cent, fat, 7 per cent, sugar, and 
2 per cent, proteids is required, proceed as follows: Cream, — ; ... A °* — — pjves 

r -l ' r v^ v-c*. j., 12 (quantity of cream used) S lvco 

6f ounces. Milk, ^_><J minus 6f equals 13! ounces. Milk sugar, 4 ° x 5 equals 2 oz. Lime- 

4 _ 100 

water q. s. to make alkaline; plain water up to 40 ounces. Mix and divide into as many 
bottles as desired. 

From this it is a simple matter to prepare the food, though it will from time to time 
be necessary to vary the proportions of some ingredients. The usual percentage of lime- 
water is five, but it is sometimes necessary to use ten or fifteen. 

Winters j gives the formulas on page 857 for the home modification of milk. 
I give these formulas in full because they are the simplest and most explicit 
with which I am acquainted. A somewhat more gradual strengthening of 
the food during the summer months should be used than is indicated in these 
formulas. As a rule, an infant of three or four months will not digest more 

*"N. Y. Med. Jour.," Mar. 20, 1898. 

t "The Feeding of Infants," Dutton & Co., Xew York, 1901. 



HYGIENE AND MANAGEMENT OF THE NEWLY BORN. 



857 



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858 THE PHYSIOLOGY OF THE NEWLY BORN. 

than i per cent, of proteid during the hot weather. During this time also 
many of the digestive disturbances may be averted by increasing the proportion 
of lime-water to one-fourth of the total quantity of the mixture. The prepared 
mixture is placed in as many bottles as there are feedings for the twenty-four 
hours, each bottle containing the amount of one feeding; the bottles are then 
stopped with sterile absorbent cotton, placed in a refrigerator, and kept 
at a temperature of 45 to 50 F. until needed. The two unerring guides to 
the quantity of each feeding are the capacity of the infant stomach and the 
amount of milk secreted by the breasts of a healthy nursing woman. The 
following table, also from Winters, shows the proper quantity, number of 
feedings, and intervals for artificial feeding up to nine months: 

TABULAR GUIDE FOR ARTIFICIAL FEEDING. 

Number of 
Age. Quantity. Feedings. Intervals. 

ist, 2d, and 3d days, £ ounce 10 2 hours. 

4th, 5th, 6th, and 7th days, . . . 1 " 10 2 

2d week, 1^ ounces. 10 2 

3d week, 2 " 10 2 

4th, 5th, and 6th weeks, 2\ 10 2 

7th, 8th, and gth weeks, 3 " 8 2^ 

3d and 4th months 3 to 4 " 7 3 

5th to 9th months, 5 to 6 " 6 3 \ 

For young infants, milk should not be added to cream. Milk and cream do 
not unite. If shaken together, and then allowed to stand for a short time, separa- 
tion is complete. The same occurs in the stomach. The stomach has practically 
to cope with whole milk. Many failures are due to this prevalent error. 

The following percentages and relative proportions of fat and proteid must 
be adhered to for successful feeding (Winters) : 

Fat. Proteid. 

First three days, 2.00 0.25 per cent. 

Succeeding days — first week, 2.50 0.33 

Second week, 3.00 0.50 " 

Third week, 3.50 0.75 

Fourth to eighth weeks, 4.00 1.00 

Ninth to twelfth weeks, 4.00 1.25 

Fourth month, 4.00 1.50 

Fifth and sixth months, 4.00 1.75 

Seventh, eighth, and ninth months, 4.00 2.00 

Tenth and eleventh months, 4.00 2.50 

Twelfth month, 4.00 3.00 

In summer the strengthening must be more gradual, as follows (Winters) : 

Fat. Proteid. 

First week, 2.00 0.25 per cent. 

Second week, 2.50 0.33 

Third and fourth weeks, 3.00 0.50 

Fifth and sixth weeks, 3.50 0.75 

Seventh week to end of third month, 4.00 1.00 

Fourth month, 4.00 1.25 

Fifth and sixth months, 4.00 1.50 

Seventh month, 4.00 1.7 c " 

Eighth and ninth months, 4.00 2.00 

General Directions. — A certain amount of systematic preparation and a 
few articles in the way of apparatus are necessary for home modification and for 
the use of the modified milk after it is prepared. These are: two or three glass 



HYGIENE AND MANAGEMENT OF THE NEWLY BORN. 



859 



jars to set the milk in, fruit-jars will do, a glass siphon, a dairy thermometer, 
a graduated measure up to 8 ounces, and a number of 4-ounce and 8-ounce 
bottles for feeding. A good supply of rubber nipples and plenty of sterilized 
cotton are necessary. A good-sized vessel for sterilization is also needed. All 
these articles are to be used sterile, and those which can stand it are subjected 
to boiling in soda, water at frequent intervals. The same feeding-bottle should 
not be used at consecutive feedings and between times should lie in a soda solu- 
tion. When the milk is received, it is allowed to stand in the sterile iars in a 





Fig. 1005. — A Good Type of Rubber 

Nipple. 



Fig. 1006. 



-A Good Type of Feeding- 
bottle. 



cool place as long as desired. The lower part may then be siphoned off and 
mixed in a sterile vessel with cream, lime-water, sterile water, and milk-sugar in 
the necessary proportions. The formulae which have been given may be used. 
When sterilization is necessary, the modified milk may be placed in the feeding- 
bottles, the mouths of which are to be plugged with sterile cotton, and placed 
in a wire rack in the sterilizing dish and lowered into the water, the temperature 
of which is then slowly raised to 167 F. and kept there for twenty minutes. 
After this the bottles are to be kept cool till needed, when they are to be warmed 




Fig. 



-Nipple Sterilizer. 



in water to between 99 and 101 F., the proper temperature for infant food. 
Not more than a day's supply of food should be prepared at a time. A complete 
outfit for the preparation of modified milk can be bought, but it is no more 
serviceable than are the articles mentioned. Whatever preparation is used, the 
greatest care as to cleanliness must be observed if good results are to be ob- 
tained. After each nursing, the bottle is rinsed in cold water which removes 
the particles of milk without coagulating them and then scalded; the nipple 
should be washed in cold water and both nipple and bottle kept in a soda 



860 THE PHYSIOLOGY OF THE NEWLY BORN. 

solution to prevent acid fermentation. The short nipple only should be used, as 
it is the only one which can be properly cleansed. While the child is feeding the 
bottle should be encased in a knitted bag to maintain the temperature as long as 
possible. The amount usually required at one nursing by a new-born child for the 
first week is one ounce, gradually increased till the sixth week, when it receives 
two and a half ounces, but the amount varies with the size of the child. The 
bottle should be held so that the child can suckle advantageously; that is, so 
that its mouth is directly opposite the summit of the nipple. Certain symptoms 
may point to the necessity of modifying the composition of the child's food; 
e. g., if it regurgitates its food unchanged, it is getting too much, or the amount 
of fluid is too large; if it takes its food eagerly but seems continually hungry 
and does not gain in weight, the proportion of solids may be increased, which 
is accomplished by diminishing the water. 




Fig. 1008. — Bottle-brush for Cleansing Feeding-bottles. 

4. Patented or Proprietary Foods. — There is one truth which by this 
time should be taken as an axiom — namely, that mother's milk is the most 
appropriate food to be taken by the infant in all stages of development and 
no patented infant food can even approximate it in value. The majority 
of such foods now on the market are either farinaceous, made from cereals 
and consisting largely of unconverted starch, or malted foods, also made 
from cereals but having the starch transformed into soluble maltose and 
dextrin. They vary in composition and strength, but as a class contain an 
excess of carbohydrates, little if any fat, and proteids which do not resemble 
those in mother's milk. Chittenden * analyzed certain proprietary foods 
according to directions for infants of six months, with the following results: 

Fat. Sugar. Proteid. Starch. 

Imperial granum, 1.54 2.71 milk 2.15 1.22 Reaction alkaline. 

Nestle 's food 0.36 0.84 " 0.81 1.99 

2 .57 cane 
Malted milk 0.68 1. 18 milk 1.15 

3.28 maltose 

o .92 dextrin 
Mellin's food, 2.89 3.25 milk 2.62 

2 .20 maltose 

o .53 dextrin 
Peptogenic milk powder, 4.38 7.26 milk 2.09 " 

Condensed milk, f 1.70 6.00 cane 1.50 " 

2.26 milk 

Open Air. — A baby can be taken into the open air when a month old in mild 
weather, and at about two months in winter. In southern climates it can of 
course go out much earlier than in northern ones. Under proper conditions the 
more open-air life a baby can have, the better. As for exercise, it should be 
allowed to kick and roll about in its crib unhampered by long, clogging skirts ; 
and to creep if it wishes, if there are no draughts near the floor. Walking 
belongs to a later period, from about the thirteenth month. 

*"N. Y. Med. Jour.," July 18, 1896. 

_ t The percentages of condensed milk are those found in the Milkmaid brand, diluted 
with seven parts water. 



HYGIENE AND MANAGEMENT OF THE NEWLY BORN. 861 

Sleep. — A very young infant will sleep about twenty-one hours of the twenty- 
four, and should be allowed to sleep and not be roused to be displayed to friends. 
It should never sleep in bed with the mother from danger of being overlaid and 
also because it is apt to be covered with the bedclothes and the fresh air kept 
from it. It should have a crib, not a rocking cradle, near the mother's bed, and 
should be laid there to sleep without previous handling or carrying about. 
Babies greatly prefer the delicate attentions of rocking and carrying, and are 
clever enough to insist upon having it if they have ever experienced it, where- 
fore it is for the peace of all concerned, as well as better for the baby's nervous 
system, not to accustom it to the luxury. Other habits may also be formed 
at a far earlier age than is usually supposed; I refer to the evacuation of the 
bladder and bowels. 

Bladder and Bowels. — It is difficult to regulate the passing of water, but 
some nurses are successful in securing a certain amount of regularity by placing 
the babies upon a vessel soon after feeding. The bowels can almost invariably be 
trained to regularity by trying to secure a movement at the same hour every day. 
There will be as many as four a day for the first week, gradually diminishing till 
there are usually two a day after the sixth month. Sometimes there is only 
one, but provided that is abundant, soft, and yellow, not lumpy, it need cause 
no anxiety. Constipation is to be avoided as it is the cause of serious troubles 
and of future bad habits. Unceasing care must be exercised to secure a good 
movement at the same hour every day, and should the child show " a constipated 
habit," or have hard, painful stools, the condition of the food must be investi- 
gated. Some infants are constipated while nursing but become perfectly 
regular when put on solid diet. Constipation in the mother will have a great 
effect on the infant's bowels, and she cannot be too careful to keep herself 
regular and avoid sweets, starchy foods, cakes, pastries, and acids. In a bottle- 
fed child the milk is found frequently to be deficient in fats. Cream and water 
will then have to be added. As far as possible the use of drugs should be avoided 
and the desired end attained by a healthful mode of life for both mother and 
child, plenty of fresh air, exercise, a rational diet, loose clothing, quiet, calm- 
ness, and regular habits. Exercise may be given in the passive form to an 
infant by gently rubbing its abdomen with a circular motion. Diarrhea is more 
often due to overnursing and overfeeding and to drinking too little water than to 
other causes. The habit of putting the child to the breast every time it cries 
defeats its own end, for it is the best way to sow the seeds of colic, vomiting, 
diarrhea, and discomfort. 

The Nursery. — When it is possible, let the nursery for the baby be a sunny 
room in which there is no plumbing and which can be well ventilated and easily 
heated. A board eight inches wide slipped under the whole length of the lower 
sash will allow of the entrance of air without draught, and a register, an open 
fire, or a stove with a pan of water always .on top, should keep the temperature 
at about 70 or preferably 6 5 F. The temperature should not vary much from 
this during the night and the fresh air should not be excluded. Whatever the 
prejudice against night air, it is better than carbonic acid gas laden with im- 
purities from the lungs, and such will be the air of a closed room in which sleep 
a child and a nurse. Cleanliness, simplicity, cheerfulness, should be the guiding 
maxims in arranging a nursery. The fewer curtains, hangings, and carpets, the 
better, as they lodge bacteria. No soiled napkins should be allowed to stay in 
the room and vessels should be removed and cleaned as soon as used. 

Environment. — Even in infancy it is well to preserve a calm environment 
about the baby. Noise, excitable actions and tones, and much prancing and 



862 THE PHYSIOLOGY OF THE NEWLY BORN. ■ 

dancing for the baby's entertainment should be avoided. Children suffer from 
too much attention in the line of amusement, and a little wholesome neglect in 
this respect will not only teach them to amuse themselves, but will induce 
calmer nerves and subsequent better health. 

Weaning. — Weaning should occur between the ninth and fourteenth months, 
but some conditions may make it desirable earlier. It is better to have it a 
gradual than a sudden process, substituting a little bread and milk, hominy, or 
other cereal for one of the regular feedings. 

Prepuce and Hood of Clitoris. — i. In male infants, beginning on the sixth 
or seventh day after birth, the nurse should be instructed to retract the prepuce 
daily, drawing it back a little every day until all adhesions are broken up, 
and the glans, as far as the corona, is exposed. It usually takes two or three 
daily attempts to completely expose the glans. Daily retraction should there- 
after be practised by the nurse and all smegma removed with a saline, boric 
acid or very weak soap solution and clean absorbent cotton. To prevent the 
readhesion of the raw surfaces, the free application of sterile vaseline between the 
prepuce and glans I have usually found sufficient. Occasionally sterile gauze 
or cotton, placed just back of the corona, will be demanded for this purpose. 
The mother or child's nurse should subsequently be instructed to repeat the 
cleansing daily during infancy, and until the boy can be taught to attend to 
the matter himself. 

Adhesions between the prepuce and glans penis are quite common, and 
are often causative factors of many reflex nervous affections and even con- 
vulsions. 

In both private and hospital practice I insist that firm adhesions shall be 
promptly reported to me. In one of my services at the New York Maternity 
two cases of persistent infantile convulsions were promptlv cured by circum- 
cision. The above described "stripping" of the glans penis will in the newly 
born usually be found a simple procedure, and it is much preferable that it 
be done in infancy by the nurse or physician, than several years later by the 
boy of six or eight. 

2. In my experience the nymphas in female infants are rarely so firmlv 
adherent to each other or to the labia majora as is the prepuce to the glans. 
This statement is based upon several thousand observations. The hood of 
the clitoris can usually be readily drawn back, and the proper cleansing secured, 
but this is not so necessary as in the case of the prepuce. 



PART NINE. 

The Pathology of the Newly Born* 



I. PATHOLOGY DUE TO INTERRUPTED PREGNANCY. PREMATURITY. 

II. AFFECTIONS OF ANTENATAL ORIGIN WHICH EXTEND INTO EXTRA- 
UTERINE LIFE. 1. Malformations and Monstrosities. 2. Acute Infec- 
tious Diseases. 3. Chronic Infectious Diseases. 4. General Conditions. 

5. Infantile Syphilis. 

III. AFFECTIONS WHICH ORIGINATE INTRA PARTUM. 1. Asphyxia Neo- 

natorum. 2. Birth Traumatisms. 3. Aspiration Pneumonia. 4. Conta- 
gious Diseases Contracted from the Mother. (1) Ophthalmia Neonatorum. 
(2) Gonorrheal Stomatitis. 

IV. DISEASES INCIDENT TO CHANGE OF ENVIRONMENT. 1. Primary 

Asphyxia of the Newly Born. 2. Atelectasis Neonatorum. 3. Failure of 
Circulation. 4. (Edema Neonatorum. 5. Failure of Digestion and Assimi- 
lation. Inanition. 6. Inanition Fever. 

V. DISEASES DUE TO BACTERIA AND FUNGI. 1. Umbilical Sepsis. 2. Septic 
Coryza. 3. Septic Pneumonia. 4. Gastrointestinal Sepsis. (1) Ulcera- 
tive Stomatitis. (2) Gangrenous Stomatitis. Noma. (3) Parotitis. 
(4) Retropharyngeal Abscess. (5) Gastro-enteritis. 5. Cutaneous Sepsis. 
(1) Dermatitis Exfoliativa (Ritter's Disease). (2) Pemphigus Acutus 
Neonatorum. Septic Pemphigus. (3) Impetigo Contagiosa Neonatorum. 
Periumbilical Pemphigus. (4) Ecthyma Neonatorum. (5) Multiple Ab- 
scess. (6) Erysipelas. 6. Tetanus. 7. Aphthae. 8. Thrush. 

VI. DISEASES OF UNKNOWN NATURE. 1. Omphalorrhagia. 2. Melena. 
3. Miscellaneous Hemorrhages. 4. Sclerema Neonatorum. 5. Buhl's 
Disease. 6. Winckel's Disease. 7. Mastitis. 8. Jaundice. 

VII. GENERAL POST=PARTUM CONDITIONS. 1. Ulceration of the Hard 
Palate. 2. Sublingual Cysts. 3. Vomiting. 4. Colic. 5. Diarrhea. 

6. Constipation. 7. Intestinal Obstruction. 8. Pneumonia. 9. Convul- 
sions. 10. Infantile Cachexia. 11. Sudden Death. 12. Medication of 
the Newly Born. 



General Considerations. — While it is customary to assign particular causes 
for individual infantile deaths, the fact must remain that in the struggle for 
existence many fetuses and newly born children are simply unable to survive, 
and that the particular disease which terminates their existence is almost a 
matter of indifference as compared with the marked predisposition to early 
death. Nevertheless, these various conditions of the fetus and newly born 




/Antenatal 


Fetal 'anaK 


/ Conditions. 


Maternal \ 


f Congenital Debility 


Dystocia \ 


Diseases and 


fatrapartum \ 


Malformations 


Cotiditwns \ 


^5fo 


Z5fc 



Fig. 1009. — Diagram showing the Mor- 
tality of the Newly Born in New 
York. — {Modified from A. Brother's 
tables.) 



Fig. 



Sepsis or 
^^Postpartum 

Jxtemiption t/Pregnaiiaf^^i™) 
(Prematurity) 
43% 



1010. — Diagram showing the Mor- 
tality of the Newly Born. 




Fig. 



-Diagram showing the Mortality of Infants in the First Year of Life. 

(Budin.*) 



must be carefully considered, because many of them are not only capable of 
producing death independently of predisposition, but are doubtless largely 
preventable. In countries in which the birth-rate is falling off from unwilling- 
ness on the part of wedded couples to procreate, the rescue of the fetus and 
newly born from some of these fatalities assumes tremendous importance. 
The pathology of the newly born comprises phases set forth above (Figs. 1009, 
1010, 1011). 

* "L'Obstetrique," September 15, 1901. 
55 865 



866 THE PATHOLOGY OF THE XEWLY BORN. 



I. PATHOLOGY DUE TO INTERRUPTION OF PREGNANCY. 

PREMATURITY. 

Introduction. — The premature expulsion of the contents of the uterus is neces- 
sarily fatal before a certain period at which the fetus becomes viable, and is 
known as abortion and miscarriage. On the other hand, interruption very 
shortly before term need not compromise the child's existence. Between these 
limits the fate of the infant is problematical. It is, of course, difficult to fix pre- 
cisely the age for survival of the child. In some statistics the mortality of these 
premature children is excessive; in others the death-rate is relatively low. 
Generally speaking, " prematurity" is an unscientific term; for death, whether 
in utero or after delivery, must have some cause, and prematurity is only a 
predisposition. No distinction can be made in practice between prematurity 
and congenital debility, and the exciting cause of death should be sought for 
in each case. But while the exact cause of death should be determined in each 
case, no one, of course, denies that true prematurity is a most common and 
potent cause of still-birth and infantile death, and that it affords a predisposition 
for the action of all other pernicious elements. The further removed the labor 
from term, the greater the influence of the predisposition (Figs. 1009, 1010, ion). 

Definition. — Prematurity might be defined as the act or state of being born 
before term. A very brief study of modern obstetrical teaching will convince 
one that this subject has never received due consideration. Premature children 
are usually regarded as constituting a large share of those congenitally weak 
infants who require special care at birth. One does not find in obstetric writings 
any sharp line of demarcation between weak premature and weak mature 
infants, at least from the practical point of view. Nevertheless prematurity 
should constitute a particular field in obstetrics and should receive adequate 
consideration from all points of view. 

Percentage of Premature Births. — The actual percentage of premature children varies 
within wide limits. In the Rotunda Hospital, Dublin, the number of premature births is but 
1 or 2 per cent. On the other hand, Braun, of Vienna, claims that his proportion of pre- 
maturity amounts to over 35 per cent, of all births. Numerous observers report a percentage 
about half-way between these figures, and the average of ten large clinics in various parts of 
the world is about 17.50 per cent., which must therefore be accepted as final. In other words, 
one birth out of six, the world over, is probably ahead of time. The great variability in 
different clinics and in the same clinic in different years is as yet inexplicable. The dis- 
crepancy in the death-rate in different clinics matches that of the birth-rate. In the 
English vital statistics 13 per cent, of the mortality of the first year of life is due to pre- 
maturity. The rate in the Paris Maternity is about 20 per cent. Rosthorn reports a 
death-rate of but 1 per cent., Ahlfeld of 2 per cent., Hofmeier of less than 3 per cent. On 
the other hand, Winckel's figures are 11.5 per cent., and the mortality in certain clinics 
runs up to 30 per cent., while a few go beyond this limit, and even one as high as 50 per 
cent. Murillo, of Santiago, Chili, has kept records for a number of consecutive years, 
and his death-rate from prematurity varies from 5 to 10 per cent. As far as may be de- 
termined, the mortality of prematurity will average something like 20 per cent., the indi- 
vidual variation and general average being much the same as those of the birth-rate. 

Etiology. — Prematurity is not solely a matter of chronology, for the develop- 
ment of the fetus does not necessarily keep pace with the calendar. A child 
may be born at term and yet be backward in development; and, conversely, 
children may be born before term and yet be fully mature. Prematurity is, 
therefore, an ambiguous term which may refer alike to the date of labor and 
the state of development of the child. Such ambiguity should not exist, and 
terms should be introduced to distinguish between these two notions. Of 



PATHOLOGY DUE TO INTERRUPTION OF PREGNANCY. 867 

these two aspects of maturity, the merely chronological phase should be regarded 
as incidental, while the element of the state of development of the fetus at birth 
should be regarded as essential. 

Symptoms. — The objective qualities of a premature child are well known 
and tolerably constant. As compared with a mature child, the premature 
infant presents a bright red color with a small quantity of vernix caseosa; 
there is a dearth of subcutaneous fat, so that the skin hangs in folds. The child 
is somnolent, has a weak cry, limp muscles, and shallow breathing. Sucking 
and swallowing are performed with difficulty. The eyes are closed. In regard 
to relative dimensions, the head is larger in proportion to the body than in 
maturity and the belly is more prominent. A still closer investigation of the 
premature child shows a number of minor peculiarities. The head is com- 
pressible, the sutures and fontanelles being wide open, and asymmetry may 
result from compression in one portion. The ears lie flat against the head. 
The skin is very delicate, showing the subcutaneous veins, and is covered 
uniformly with lanugo. The nails are soft and do not extend to the ends 
of the fingers. From the twentieth to the twenty-fourth week the lanugo and 
vernix caseosa first appear; the scalp hair has become differentiated. In the 
male the scrotum is small, and as yet empty, while in the female the labia 
majora are separated by the clitoris. The surface of the child is bright red. 
Children born at this period can move and breathe. (Compare page 85.) From 
the twenty-fourth to the twenty-eighth week subcutaneous fat begins to 
appear in the region of the neck, shoulders, and breast. The nails are represented 
only by firm folds of integument. Children born during this period are able 
to cry softly. (Compare page 85.) From the twenty-eighth to the thirty- 
second week the pupillary membrane disappears, the intense red color fades 
out, the subcutaneous fat becomes diffused over the body, and the nails are 
developed nearly as far as the finger-tips. Children born during this period are 
viable. (Compare page 85.) From the thirty-second to the thirty-sixth week 
the child resembles a mature infant, the differences being of degree only. Thus, 
there is less subcutaneous fat present, so that the skin is somewhat wrinkled; 
the cranial bones are more pliable, the nails are shorter and less firm, and the 
lanugo is more abundant. The scrotum of a male child born at this period 
exhibits wrinkles and folds. (Compare page 86.) 

Physiological Peculiarities. — The premature child has physiological as well 
as anatomical peculiarities. In heat-making power it is defective, doubtless 
because of its imperfect respiration, and the temperature constantly fluctuates 
by reason of the defective action of the heat-regulating mechanism or instability 
of the respiratory center. The thorax is somewhat inelastic and the lungs are 
prone to atelectasis. Respiration is carried on only by the anterior portion 
of the lungs. The premature child does not regain its initial loss of weight 
for a month. Naturally these infants are ill fitted to sustain the traumatisms 
of labor, where the compression favors congestion and hemorrhage. I have 
often noted the frequency of ecchymoses in breech deliveries of the premature. 
Interstitial hemorrhage into the nervous centers is doubtless favored, with 
production of athetosis and cerebral diplegia. In addition to the natural 
inability to nurse, the contact of the rubber nipple or teaspoon, as well as the 
operation of gavage, is a source of dangerous irritation. The premature child 
is especially liable to hernia, both inguinal and umbilical, because its orifices 
are insufficiently closed. The descent of the testicle also favors inguinal hernia. 
The first attempts at respiration may provoke fatal paroxysms of cyanosis. 
While some authorities mention a "premature" quality of pulse and respiration, 



868 THE PATHOLOGY OF THE NEWLY BORN. 

a pulse of 140 and respiration of 40 to 60 are not incompatible with perfect 
health. Anuria is sometimes seen in the premature. Determination of the age 
of the fetus by the calendar is at best very difficult, for obvious reasons. Prac- 
tical obstetrics recognizes no distinction in congenitally feeble children inde- 
pendent of the date of birth. It is better, I believe, to do away with the 
element of time in these cases and to be guided solely by the state of develop- 
ment of the child. At the same time, however, in the matter of artificially 
induced premature delivery, we have to rely largely upon the calendar, because 
we have no resources by which we may be able to estimate the degree of develop- 
ment of the child in utero. The newly developed science of external cephalom- 
etry, as practised to-day in Paris, may possibly become effective in determining 
the degree of development through intrauterine mensuration of the head. 
(Compare page 187.) At present the real criterion of maturity is the develop- 
ment of the child at birth. Of the various criteria proposed, some authorities 
prefer the temperature; others, the dimensions and weight. Eross, of Budapest, 
made 11 50 measurements in 50 premature children. Of them, 19 had normal 
temperature, 18 hyperthermia (due to some febrile complication), while in the 
remaining 13 the temperature was subnormal. To estimate the degree of pre- 
maturity or debility we must consider (1) age (development), (2) weight, (3) 
temperature. Budin regards every newly born infant with a rectal temperature 
of not more than 90 F. (32 C.) as a candidate for the incubator. Some would 
regard all children as congenitally feeble whose weight does not exceed 4.37 
pounds (2000 grams); others make the limit 5 J pounds (2500 grams). In 
regard to the causes of congenital debility, we find children born at term who 
are nevertheless premature in development when the mother suffered during 
gestation from anemia, hyperemesis, and cancerous cachexia. At the same 
time very poorly nourished women may bear fine children. 

Prognosis. — The prognosis varies with the degree of prematurity and the 
■development of the infant. A child born but a few weeks before full term, 
with a vigorous cry, circulation well established, and capable of taking nourish- 
ment, will require scarcely more attention than a full-term baby, but, as a 
rule, in premature infants the problem of feeding and maintaining the animal 
heat is not easy to solve. Premature infants or those inherently delicate 
require the utmost care and attention. Only a small proportion of children 
born before the seventh month survive, but after the seventh month, the recog- 
nized period of viability, the percentage of infants saved varies from 50 to 
96. The nearer full term, the greater the child's chances of life. These 
premature infants are usually very small, weighing four pounds or less. They 
have feeble muscular power, the cry is faint or whining in character, the skin 
is soft and delicate, the respirations are shallow, and the entire appearance is 
one of extreme weakness. The temperature is usually subnormal. The powers 
of suckling are feeble and the infants swallow with difficulty. 

Treatment. — There are three main principles in the treatment of prema- 
turity: (1) The temperature immediately surrounding the child should be such 
as is adapted to its requirements; (2) its nutrition should be maintained by 
proper feeding; (3) the amount of handling or other disturbance should be re- 
duced to a minimum. 

Management at Birth. — The temperature of the lying-in room should 
be carefully regulated and the child should be handled with the greatest care 
from the moment of birth. The rule that the cord should not be ligated until 
it has ceased pulsating is here obviously of special importance. Meanwhile the 
child should be wrapped in warm blankets. As soon as the cord is ligated 



PATHOLOGY DUE TO INTERRUPTION OF PREGNANCY. 869 

the child should be thoroughly wrapped in warm cotton batting, the face only 
being uncovered. It should then be wrapped in warm blankets and transferred 
to the incubator. If artificial respiration is necessary, those methods which 
involve the most rough handling and exposure to cold should be avoided if 
possible. (See page 884.) 

Bathing; Dressing. — Premature children should not be bathed, but may 
be cleansed as becomes necessary with a soft cloth and warm sweet oil. The 
action of the skin may be improved by anointing the body every two or three 
days with the same material. All handling not absolutely necessary should 
be prohibited. The child enveloped in warm cotton batting or in the heated 
air of the incubator needs no clothing except a diaper, and should have none, 
since even the passive movements necessary in dressing are somewhat of a 
shock to these feeble children. Absorbent cotton, which may be used and 
thrown away as required, should be preferred to the ordinary diaper. Chafing 
should be carefully guarded against. 

Alimentation. — Ordinarily the weakened condition of the infant precludes 
the possibility of nursing the breast or of taking the proper amount of nourish- 
ment from a bottle. Feeding with a small medicine-dropper, at intervals of 
one or two hours, is a good plan. The amount given at each feeding depends 
on the capacity of the infant. One-half ounce is a proper amount to begin 
with. In many cases, however, gavage, or forced feeding, — described else- 
where, — is indispensable. Breast-milk from a woman having a child between 
two or three weeks and several months old is the best form of nourishment, 
and when given makes the prognosis decidedly better. Equal parts of cane- 
or milk-sugar solution should be added to the breast-milk. Cow's milk is em- 
ployed only when it is impossible to obtain breast-milk, and then in weak pro- 
portions. I have used modifications containing fat, 0.5 to 1 ; sugar, 4.0 to 8.0; 
and proteids, 0.25 to 0.75 with success. The amount and frequency of such feed- 
ings are increased as the infant's nutrition warrants. Plain sterile water should 
be given freely; it adds to the body-weight and helps elimination through skin, 
bowels, and kidneys. These children must be fed in proportion to their weight, 
which may not exceed 4 pounds (1800 grams). They must be fed promptly 
after birth; insufficient nourishment is expressed by cyanosis, almost inevitably 
a fatal prognostic symptom. Budin sought to determine the stomach capacities 
of these children by autopsies upon fetuses of different uterine ages, and quite 
recently Planchon * has proceeded with a similar aim in a different fashion. 
While Budin experimented with the cadaveric stomach, Planchon's work has 
been done upon the living subject. An account was taken of the quantity of 
milk ingested, whether from the breast or by gavage, spoon-feeding or drinking 
from a glass. It was ascertained that the amount of milk increased with each 
day, and the heavier the child, the greater the amount of milk taken. 

Gavage. — In the treatment of premature and congenitally weak infants, 
it is necessary at times to resort to gavage or forced feeding, by which is meant 
the introduction of food into the stomach by a tube. A small funnel of rubber 
or glass, two feet of rubber tubing, a No. 7 French scale rubber catheter, and 
a small glass tube three inches long to connect the tubing with the catheter, are 
what will be required — practically the same apparatus used in stomach wash- 
ing. When gavage is to be performed, the infant should lie flat on its back 
in the arms of a nurse, the arms held at the sides, and the head steadied 
by an assistant. The catheter is then quickly passed into the stomach 
and the food poured into the funnel, which is raised. As soon as the funnel 

.*" L'Obstetrique," 1901, vi, No. 5. 



70 



THE PATHOLOGY OF THE NEWLY BORN. 



is empty the catheter is withdrawn, pinching it to prevent the escape of any 
fluid into the pharynx. In very young infants the jaws can readily be separated 
by the fingers of the operator; in older children a mouth-gag may be required. 



k 







v 



,/■■ 






/ 



Fig. 1012. — The Operation of Stomach Washing (Lavage). For forced feeding (gavage) 
the infant is placed flat on its back. The same apparatus is used in both procedures, 
and both operations are valuable in the treatment of premature and congenitally 
weak infants. 



If the food is regurgitated, the process should be repeated. After feeding the 
child should be kept as quiet as possible. The children nourished in this manner 
should be fed at longer intervals than those suited to other conditions, the length 
of the interval being determined by the requirements in each case. It is a good 



PATHOLOGY DUE TO INTERRUPTION OF PREGNANCY. 



871 



plan to wash the stomach before the first feeding of the day (Fig. 101 2). Gavage 
is more largely used in the treatment of premature infants kept in incubators, 
but it is also indicated after operations on the nose and throat and about the 
neck, and in habitual vomiting. Food given by a tube often remains in the 
stomach when other methods of feeding are followed by vomiting. In certain 
serious conditions, such as pneumonia, diphtheria, and scarlet fever, the life of 
the, child may depend upon gavage. In cases in which disease of the mouth, 
spasm of the muscles of the jaws, or intu- 
bation renders swallowing difficult or im- 
possible, nasal feeding is resorted to. A 
soft-rubber catheter lubricated with vaselin 
or glycerin is gently pushed into the 
nostril, through the pharynx into the 
esophagus and stomach, and the feeding 
accomplished as described above. Stimu- 
lants and other medicines may be given 
by these methods. 

Incubation. — History: According to 
Baumm,* the first incubator was devised 
by Denuce, of Bordeaux, in 1857. Crede's 
apparatus dates from 1864, and served 
as a model for many years. In 1880 
Winckel introduced his permanent water- 
bath to the profession, but it proved 
cumbersome. Tarnier's incubator dates 
from the same period. Quite recently 
numerous improvements have been added 
to the older incubators and new designs 
have been introduced. At present the 
well-known "Lion couveuse" takes pre- 
cedence overall others. It is self-regulat- 
ing within two degrees (Fig. 1013). In the 
absence of an incubator, or until one can 
be procured in private practice, the appli- 
cation of artificial heat may be carried out 
by swaddling the infant in raw cotton, 
head and all, leaving only the face ex- 
posed, wrapping it about with a blanket 
and tying it around with a roller bandage. 
Hot bottles should be placed on each side 
of it. A very convenient method is to 
place the infant in a baby's basket half- 
full of raw cotton in which numerous hot 
bottles have been placed. The only other 
covering is a diaper and a shirt. The temperature of the room should be com- 
fortably warm, particularly when the infant is stripped for a rubbing with 
oil. When these means fail to meet the indications, an incubator must be 
employed. f Action: When a child is placed in the incubator, its pulse and 




Fig. 1013. — A Good Type of Incuba- 
tor or Couveuse. (Lion Pattern.) 



* "Allgem. med. Ztg.," April 4, 1900. 

f The Lion Incubator may now be rented in New York city from The Kny-Scheerer 
Co., 225 Fourth Avenue, New York, at a cost of $5.00 for installation, $5.00 for removal, and 
50 cents per day for rental. 



872 THE PATHOLOGY OF THE NEWLY BORN. 

respiration are slightly accelerated, returning to the normal toward the sixth 
day, save that the respiration still remains slightly increased. The peripheral 
temperature is increased to a higher degree in the axilla than in the rectum. 
Proper temperature: It may vary from 86° to 98. 6° F. (30 to 37 C.) according to 
the circumstances. Tarnier thought the average should be about 90 F. (32 C), 
Pinard 93 F. (34 C), while Colrat claimed that a higher temperature than 
86° F. (30 C.) was discomforting to the child. Bonnaire obtained good results 
at 90 F. (32° C). This temperature, 90 F., I have found to be satisfactory, 
although as high as 95 F. (35 C.) is occasionally required. Whatever the 
initial temperature, it should gradually be diminished, and it should descend 
to 77 F. (25 C.) before the child is withdrawn from the incubator. Dangers: 
The incubator is not unanimously recommended for prematurity. Serious 
objections are found to its use. The trouble with the premature child is 
a lack of thermogenic power, rather than superradiation. Hence, the incu- 
bator is essentially meddlesome and possibly contraindicated. The air of the 
incubator necessarily becomes foul, but this is somewhat offset by the method 
of construction of the latest models. The sudden change of the child's tem- 
perature when it is taken from the incubator to be bathed, etc., has never 
been shown to be prejudicial, despite the views of theorists. The possibility 
of the transmission of disease by the apparatus must receive the most serious 
consideration, and constitutes a weighty contraindication to its employment. 
The danger here is twofold, for the child may not only contaminate itself from 
a putrefying cord or feces, but the incubator serves well for the incubation 
and maintenance of germs which may infect the next child destined to occupy the 
apparatus. The problem of ventilation has not yet been solved. Most modern 
incubators are entirely too small for the amount of air required by the child. 
There is a serious danger in the possibility of suffocation in connection with 
vomiting, and to avoid this, constant supervision is necessary. In a case of 
Wormser's a child choked to death, milk coagula having been found in the 
bronchi. The closed incubator made it impossible to hear the warning cough 
of the child, which should have been kept out of the incubator for some time 
after feeding. Baumm's studies with the "Lion couveuse" gave the following 
results: At 98. 6° F. (37 C.) 200 cubic inches (3300 c.c.) of air are admitted 
every second, which means that the entire air of the couveuse is renewed every 
minute. This amount is fully sufficient for all demands. A child which has 
been in the incubator two hours shows in the waste air a gain of carbonic acid 
amounting to but 0.16 per thousand, showing that the purification of the air 
of the incubator has been very complete. As to the children suited for the 
incubator, there is no necessary relationship between weight and vigor on the 
one hand, and production of heat on the other. A child which has subnormal 
temperature and cannot be kept warm by packing should go to the incubator. 
Duration of Treatment. — The child should be fed till it is able to nurse 
without exhaustion. Seven months' children will probably need to be fed for 
weeks, while those of eight months may be able to nurse. The duration of 
the child's stay in the incubator will vary with its progress and development. 
It may not be necessary to keep it there till full term. Attempts at discon- 
tinuing the treatment should be cautious and tentative. The temperature 
of the apparatus should be lowered gradually. As the child grows stronger, it 
may be taught to nurse by feeding it through a nipple shield, which should be 
perfectly clean.* 

* Statistical. — In 1900 Berend and Deutsch ("Arch. f. Kinderheilkunde," xxviii, 1900) 
addressed 170 letters of inquiry to the chiefs of maternities in Europe and America in 



ANTENATAL AFFECTIONS IN EXTRAUTERINE LIFE. 873 



II. AFFECTIONS OF ANTENATAL ORIGIN WHICH EXTEND 
INTO EXTRAUTERINE LIFE. 

I. Malformations and Monstrosities. 2. Acute Infectious Diseases. 3. Chronic Infectious 
Diseases. 4. General Conditions. 5. Infantile Syphilis. 

It has already been stated in the section upon this subject that the fetus 
may be attacked in utero by a number of conditions, many of which render its sur- 
vival impossible (pages 259 and 285). If the pernicious influences are exerted 
during the embryonal period, certain malformations and monstrosities arise, some 
of which are compatible with survival. During the fetal period pathogenic influ- 
ences produce alterations more like those seen in extrauterine life. But aside 
from definite diseases, it is probable that in many toxic or cachectic states 
of the mother the fetus undergoes a sort of arrest of development or stunting, 
so that it presents many of the phenomena of prematurity. No distinction is 
possible between a condition which breaks out in utero and one which appears 
just after delivery. It is certain that the agencies which produce the disease 
act in utero, and if their action is exerted very late in pregnancy, or if it super- 
induce labor, the manifestations of the disease will occur post partum. An 
antenatal affection may run its course before delivery takes place; or may begin 
before birth and complete its cycle post partum; or, finally, may be contracted 
before labor, but manifested only afterward. 

1. Malformations and Monstrosities. — The various congenital malformations 
and monstrosities have been described elsewhere (Part III). Of the lesser 
monsters, some are compatible with survival (harelip, exstrophy of the bladder, 
etc.); some naturally incompatible with survival are amenable to treatment 
(imperforate rectum, etc.), while others, likewise incompatible with survival, 
are also beyond the resources of treatment; e. g., imperforate esophagus. Of 
the major monstrosities, many cases of teratomelus are capable of survival 
(phocomelus [Fig. 356], etc.), but other single monsters can live only when the 
malformation is very slight, as in the first degree of cyclopia. 

2. Acute Infectious Diseases. — Children have been born with a full variolous 
eruption, or the exanthem may not appear until several days post .partum. 
Such cases occur very infrequently. The child dies as a rule, but recovery 
has been recorded. Both variola and vaccinia of the mother may confer im- 
munity toward smallpox on children who have escaped actual infection in utero, 
but such immunity is short-lived. In the recorded cases of measles the children 
have always been born with full rash, the disease apparently exploding in the 
mother and fetus at the same time. It is otherwise with scarlatina, which in 
some cases has not broken out in the child until the first day post partum. 
In a few cases the newly born have been healthy at first, but contracted the 
maternal disease secondarily, probably from the breast-milk. No case of intra- 

regard to congenital debility. They received about thirty-six replies, the most satisfactory 
of which were from Wiirzburg, Prague, Bologna, and Dublin. The circular letter referred 
to comprised eight queries, viz.: (1) What percentage of new-born children are premature? 
(2) What is the mortality of the new-born? (3) Is the incubator used? (4) Is it dis- 
infected? (5) What is the average number of days spent in the incubator? (6) Has the 
incubator lessened the mortality among the premature? (7) If no incubator is used, what 
replaces it? (8) What is the mode of feeding? In regard to the use of the incubator 
32 answers from clinics were received by Berend and Deutsch. It appears that but three 
institutions use the Lion couveuse; 11 the Tarnier-Auvard apparatus; 7 the Crede apparatus; 
while in the other 11 the old custom of wrapping the children in cotton still obtains. In 
regard to the temperature of the incubator, "it should vary inversely with that of the child." 



874 



THE PATHOLOGY OF THE NEWLY BORN. 



uterine transmission of diphtheria is known, but the newly born have been infected 
through other channels when the mother was suffering from the disease. The chil- 
dren born of women with typhoid fever exhibit a high degree of congenital debility 
and often succumb. The same is true of the children of malarious mothers who 



1NTE5T1NE5 






3^ 

Cor a 



sPirtM 



m -■ v 




Fig. 1014. — Large Umbilical Hernia ix the Newly Borx Containing a Portion of 
the Intestines, Liver, Stomach, and Spleen. — (Author's case.) 



also show at times positive evidences of the disease itself (congenitally enlarged 
spleen, etc.). Children may, of course, be bitten soon after delivery by infected 
mosquitos, and, generally speaking, malaria may from one cause or another 
be- encountered in the newly born of highly malarious districts. It presents 
but little difference from the type found in older individuals. Children have been 

born with the evidences of 



N^ 




l l M 






influenza. In regard to sep- 
sis of the newly born which 
has been contracted in utero, 
children have been born with 
a septic form of pneumonia, 
and it is supposed that some 
of them survive this experi- 
ence, although this is only 
an inference. Children have 
been born of rheumatic 
mothers with all the phe- 
nomena of acute rheuma- 
tism. For further informa- 
tion upon this and analogous 
affections, see Antenatal Dis- 
eases, page 285. 

3. Chronic Infectious Dis- 
eases. — In a very few cases of actual congenital tuberculosis the children 
were born tuberculous, succumbing to the disease within a short time. The 
offspring of tuberculous mothers, while almost invariably free from tubercu- 
losis, exhibit a high degree of congenital debility and perish readily from 




H 



Fig. 1015. — Congenital 
Hard Palate, Cleft 



Bilateral Fissure of the 
Soft Palate, and Slight 



Degree of Hare-lip. — (Author's case.) 



ANTENATAL AFFECTIONS IN EXTRAUTERINE LIFE. 875 

secondary mortality. It is not unlikely that some of the children of the 
tuberculous are born with the virulent bacilli in their tissues and are 
doomed to be infected perhaps forthwith, perhaps not until adolescence. If 
fetal syphilis does not prove fatal in utero, — a rare exception to the general 
rule, — the child, in addition to the visceral lesions already described (page 
290), presents certain phenomena which are due evidently to failure in adjusting 
itself to the new surroundings. Such infants can survive but a short time, 
and their condition is known as syphilis neonatorum, to distinguish it from 
syphilis contracted in utero, which does not manifest itself until a month or 
thereabouts after delivery. This latter type, being extremely common, is the 
familiar infantile or congenital syphilis. A peculiarity of syphilis of the newly 
born is the general tendency to hemorrhage. The characteristic lesions of this 
phase of syphilis comprise bullae which may exceptionally begin in utero, but 
as a rule tend to appear soon after birth. Their seat of predilection is the 
palms and soles, and they should not be confounded with septic pemphigus of 
the newly born (Fig. 1016). These bullae have a hemorrhagic tendency, and the 
same disposition to bleed found in most of the tissues of the body constitutes 
a sort of scorbutus of syphilitic origin. Aside from the bullae and general 
hemorrhagic diathesis, these children may present all the lesions described under 
the head of fetal syphilis. 

4. General Conditions. — Chronic metal poisoning of the mother, alcoholism, 
nicotinism, diabetes, albuminuria and eclampsia, and the cancerous cachexia all 
tend to the production of weak, undersized fetuses with a high degree of secon- 
dary mortality. Lead-poisoning, alcoholism, and albuminuria also tend specially 
to cause convulsions and bestow a highly neuropathic organization upon the 
child. The offspring of the highly neurotic, hysterical, epileptic, and psycho- 
pathic individual also develop these tendencies, but here it is an affair of pure 
heredity. Children who appear normal at birth but develop tendencies in later 
life are not included under the pathology of the newly born. Ballantyne, for 
the same reason, does not describe hereditary chorea, hereditary ataxia, Thorn- 
sen's disease, etc., under affections of the newly born. In regard to the various 
local diseases which develop in utero, survival is largely a matter of accident. 
In fetal ichthyosis of the grave type, for example, one victim of the disease 
lived to the age of five months. Children with fetal anasarca have lived at 
most but a few days after birth. An infant with congenital cystic elephantiasis 
is known to have survived for twenty months. These are mere curiosities of 
medicine, for as a general rule children with the aforesaid affections are practi- 
cally still-born, living at most but a few minutes. The condition known as 
simple congenital elephantiasis, characterized by overgrowth of the soft parts of 
a limb, is entirely compatible with life. The same is true of the mild form 
of ichthyosis. Other congenital affections in which survival readily occurs are 
keratolysis, tylosis, anomalies of the pilous system, etc. The conditions com- 
prised under the term fetal rickets are not incompatible with life. Children born 
with ascites seldom survive, but this is due principally to the relative impossi- 
bility of birth without mutilation. At least one case has shown that this 
affection is not per se incompatible with life. In peritonitis, as distinguished 
from ascites, a brief extrauterine existence has been recorded. In congenital 
obliteration of the bile-ducts the children may survive for a longer or shorter 
interval, but the prognosis is almost hopeless, and the same is true of congenital 
hypertrophic stenosis of the pylorus, in which three months is considered the limit 
of life. In fetal endocarditis there is an indefinite period of survival with occa- 
sional recovery. Nephritis contracted apparently in utero proves fatal within a 



876 



THE PATHOLOGY OF THE NEWLY BORN. 



short time after delivery ; one infant lived twenty-one days. If the degree of 
hydrocephalus is not too extensive to prevent birth alive, or if the disease is 
just beginning, the patients may survive for some years. It is evident that 
the group of diseases of intrauterine origin which persist into extrauterine 
existence is not one of great importance. The most important is hydrocephalus, 
which, while of intrauterine origin, persists as one of the most important diseases 
of infancy. Congenital debility, characterized by small size and low weight, 
evidences of prematurity, subnormal temperature, etc., while not a disease, is 
a very common and important legacy of the antenatal period which may arise 
from a host of maternal conditions and which may predispose the individual 
to an early death under a variety of forms. 

5. Infantile Syphilis. — Syphilis in infants is either congenital or a postnatal 
infection. (See Antenatal Syphilis, page 290.) In the first instance it is 
hereditary ; in the second, an acquired disease with initial lesion and its sequences, 
which do not differ from those of later life except in the modifications which 
fetal tissue may bring about. Heredity is seen following syphilis of one or 

both parents. Infection from the father 
is most frequent and least severe, be- 
cause influence ceases with impregna- 
tion. It is most depressing in double 
heredity, but maternal cases, owing to 
the nine months of interchange between 
the fluids of the fetus and the mother, 
show a mortality almost as high. Ac- 
cording to Fournier's statistics of five 
hundred cases, one-third are fatal from 
transmission from the father, 60 per 
cent, from the mother, and 68 per cent, 
in mixed descent. These figures are 
very materially modified by prompt 
treatment. For pathology and symp- 
toms, see Antenatal Syphilis, Part III. - 
Diagnosis. — To aid in the diagnosis 
of early inherited syphilis, there may 
be a history of disease or evident efflor- 
escence in one or both parents, or the tale of repeated abortion may be elicited 
at progressively retarded periods, the fetuses being macerated, shriveled, with 
enlarged, lobulated livers, skin eruptions, or hydrocephalus. The infant pre- 
sents signs of the disease at birth or they develop in a few days. It may be 
rosy and well nourished, but is oftenest emaciated, gray in hue, with a senile 
facies. The palms and soles show red areas on which bulla? develop, moist 
papules are seen around the anus and mouth, the mouth is filled with sores. 
The baby has difficulty in nursing, breathes through the mouth, and snuffles 
continually. The cry is feeble and hoarse; there may be a persistent bronchitis. 
The eyes present no symptoms or there are a ciliary injection and photophobia. 
The end of one or more of the long bones shows an inflammatory enlargement. 
All symptoms may be absent when a parent is known to be syphilitic. The 
child must then be watched for developments (Fig. 10 16). 

Prognosis— This is practically entirely dependent on treatment if the child is 
viable. Mortality in maternal descent is reduced from 60 to 3 per cent. Re- 
currence is unfortunately apt to occur, and in the shape of destructive lesions 
later in life, but the large percentage of relapses is due to insufficient medication 





Fig. 1016. — Syphilitic Pemphigus in the 
Newly Born. — {Lepage.) 



ANTENATAL AFFECTIONS IN EXTRAUTERINE LIFE. 877 

at the outset. Certain cases succumb to marasmus in spite of all that can be done. 
As to the viability of a fetus, the prognosis is better as the parental syphilis 
increases in age and as attention has been paid to treatment. Much can be 
done in the way of prevention by careful mercurialization of the mother during 
pregnancy. 

Treatment. — Inunction should be instituted as soon as the diagnosis is made. 
It is best done by smearing mercurial ointment under the belly-band, where the 

subcutaneous 

fat Periosteum 




Fig. 1017. — Syphilitic Osteochondritis in the Newly Born. Longitudinal Section. 
X 100. — {From a specimen in the Pathological Laboratory of the Cornell University 
Medical College.) 



child's movements will cause its absorption. The white precipitate or blue 
ointment maybe used, a half-drachm of either, mixed with an equal part of lanolin, 
daily until the symptoms have disappeared, then every other day for a month. 
After that time the inunctions are continued with intermissions for a year, 
or internal medication in the form of gray powder or the protiodid or tannate 
may be substituted. It is well while mercury is being given systematically to 
administer a little iron from time to time in the shape of the syrup of the iodid. 



878 THE PATHOLOGY OF THE NEWLY BORN. 

It is not enough to medicate the mother. The method is inaccurate and most 
unscientific, but there is small hope for the child if she does not nurse it. Wet- 
nursing is not to be considered on account of contagion, unless the nurse is 
syphilitic. Medication should be continued for at least a year, but the child 
should be kept under observation for two years. 



III. AFFECTIONS WHICH ORIGINATE INTRA PARTUM. 

I. Asphyxia Neonatorum. 2. Birth Traumatisms. 3. Aspiration Pneumonia. 4. Con- 
tagious Diseases Contracted from the Mother. (1) Ophthalmia Neonatorum. (2) Gonor- 
rheal Stomatitis. 

Here belong most of the cases of asphyxia, the various birth traumatisms, 
aspiration pneumonia, and contagious diseases — chiefly gonorrhea — contracted 
from the mother sub partu. So-called intranatal affections constitute a well- 
defined group which in general bears little relation to antenatal or neonatal 
disease. Some confusion may occur in the case of sepsis, which may be con- 
tracted at any period of existence, whether intrauterine or extrauterine. The 
pathogenic factors which operate intra partum may be mechanical or bac- 
terial. The former consist largely of compression of the fetus, either by the 
maternal passages or by the forceps, and of traction by the medical attendant or 
of aspiration by the fetus of liquor amnii. The latter comprise a number of 
germ infections, one of which, however, stands out with prominence over all 
others: viz., gonorrheal ophthalmia. The mechanical element is equivalent to 
the entire subject of dystocia. The immediate results of mechanical compression 
may be general or local. There are but two examples of the general character. 
(1) Asphyxia: Here the compression is of such a character that the aeration of 
the fetal blood becomes arrested. (2) Apoplexy: Compression of the skull some- 
times leads to endocranial hemorrhage, which may cause the death of the fetus, 
or, if the latter survives, paralysis. 

1. ASPHYXIA NEONATORUM. 

Synonyms : Apncea neonatorum ; asphyxia nascentium. 

Introduction. — This subject, at first sight one of great simplicity, is in reality one of 
the most difficult in the entire subject of obstetrics. The simple and straightforward 
manner in which it is presented by the great majority of authors involves a discreet sup- 
pression of numerous problems which would otherwise confuse and perplex the student. 
Nevertheless I deem it the wiser plan to face these difficulties and to attempt, at least, 
to distinguish between what is clear and what is obscure. Asphyxia neonatorum is one 
of the neglected connecting links between two specialties — obstetrics and pediatrics. Each 
one of these has apparently been perfectly willing to abandon its care of this subject to 
the other; each has considered it in a fragmentary way. The result has been that im- 
portant phases of the subject still await investigation and our knowledge of it is imperfect. 
Definition. — Before a definition can be made it will be necessary to analyze the meaning 
of the terms in use. What is meant by asphyxia, whether the word is used in a general 
sense or refers only to the newly born, is practically defective aeration of the blood, and 
this deficiency may be slight or extreme. While I do not advise the doing away with 
a term so universally employed as asphyxia, I prefer, when possible, to substitute some 
such expression as "subaeration." The term apnea, which has been proposed as a sub- 
stitute for asphyxia, is open to the same objection as the latter word, and Ahlfeld has 
suggested that it be used to represent the physiological inactivity of the fetal lungs up 
to the time of ligation of the cord. Such terms as "suspended animation " and "apparent 
death," often proposed as substitutes for asphyxia neonatorum, appear to be even more ob- 
jectionable than the latter, and, as a matter of fact, all the synonyms and substitutes thus 
far proposed appear to be applicable only to the terminal stage of subaeration of the blood. 

Varieties. — The subject of asphyxia neonatorum consists of a number of 
different conditions which have a common tendency. Thus, when the child 



AFFECTIONS WHICH ORIGINATE INTRA PARTUM. 879 

is in titer o and labor is not impending various agencies may compress the cord 
and bring about the death of the fetus. Such a state of affairs might be termed 
"subaeration from cord compression ante partum " and might be fatal im- 
mediately, or if the constriction were not complete, a chronic condition would 
be set up, manifested by some form of arrested development. Under these 
circumstances the term "intrauterine asphyxia" would apply. If the child is 
alive and well up to the moment of the onset of labor, and during this act the 
cord is compressed, we should then have a condition of subaeration from cord 
compression intra partum. If the subaeration were complete, the child would 
be dead long before it could be extracted ; but if only partial or temporary, it 
might be possible to reanimate the child after delivery. The cord being free 
from compression, the very act of labor itself in compressing the skull and 
thorax, and the added compression of the forceps when the latter is applied, 
will give rise to a condition which may be described as "subaeration from com- 
pression of the skull (intrapartum)." What has been said of cord compression 
applies equally to disturbance of placental circulation in situ, and pre- 
mature detachment of placenta. Some cases of this form are simple, others 
are complicated by intracranial hemorrhage ; so that the children are born both 
asphyxiated and with paralyses of central origin. It is probable that most of 
the infants that are born in a state of subaeration from which they may be re- 
animated are examples of simple compression of the skull. If the child is 
born alive and does not begin to respire until the cord is cut, the condition 
has been termed physiological apnea. Many children utter no cry at birth 
and respiration is so shallow that it escapes observation. This is known as 
"false asphyxia." The child is doubtless in a condition of subaeration because 
the cord has been cut and the breathing is incomplete. From the fact that 
these children soon begin to breathe more naturally, the condition may be 
regarded as physiological. This class of cases doubtless passes by imperceptible 
degrees into a more serious one, especially noted in congenitally feeble and 
premature children. Here the child attempts to breathe, but is unequal to the 
task of aerating its blood. It becomes cyanotic and succumbs at a variable 
period after birth. This might be termed "subaeration from prematurity or 
debility, post partum." When we consider that two or more of the preceding 
types of subaeration may coexist in the same child, the extreme complexity 
of the subject is apparent. The list might also be extended; thus, fetal sub- 
aeration is doubtless present in certain diseases of the mother, especially in 
convulsions, and in any maternal affection in which the blood is imperfectly 
aerated, particularly in cardiac and pulmonary diseases. Again, during labor 
chloroform narcosis may favor subaeration in the fetus. 

Pathology. — Pathological changes may be due to the asphyxia itself, in which 
case the blood is fluid, the right heart engorged, and the large thoracic vessels, 
sinuses of the dura, and hepatic vessels are in a state of distention. Extravasa- 
tions often accompany the distention, especially in the viscera, and oedema 
has been noted in the pia, scrotum, and cord. Another set of pathological 
changes is found in the thoracic organs in cases in which premature respiration 
has occurred. In these cases the trachea and bronchi may be filled with mucus, 
amniotic fluid, meconium, etc. (Fig. 1018). Such substances constitute a demon- 
stration of the fact that intrauterine respiration has occurred. These fluids 
may, however, be prevented from entering the trachea by the interposition 
of the membranes or the close contact of the maternal parts. The stomach 
may also contain meconium. Pulmonary ecchymoses are less frequent here 
than in post-natal asphyxia. In this form the evidences of premature respira- 



880 



THE PATHOLOGY OF THE NEWLY BORN. 



tion are absent. General atelectasis will be found, even in children who have 
been reanimated. The pathological changes in the intrauterine form are 
analogous to those of ordinary suffocation. The blood, which is thin, fills the 
cerebral sinuses. The membranes are cedematous. The lungs have a dark hue 
and the respiratory passages are filled with liquor amnii and debris. Occasion- 
ally air is found in the lungs. Extravasations and ecchymoses are found in the 

various organs, which are con- 
gested (Fig. 1018). Soft, dark 
clots distend the right heart. 
In the extrauterine form we 
often find large areas of ate- 
lectasis in the lungs. There 
will be visible the external 
signs of the forces that 
have produced the condition. 
The organs exhibit structural 
changes. The lungs and 
heart as well as the dia- 
phragm and brain are often 
imperfectly formed. Intra- 
uterine pneumonia or pleurisy 
may be present. When in- 
effectual respiratory efforts 
have occurred, the lungs are 
more markedly congested and 
numerous hemorrhages are 
scattered over the visceral 
pleura. The lungs are en- 
gorged to such an extent that 
they are heavier than water; 
when immersed they sink at 
once. One proof of prema- 
ture respiratory efforts is the 
presence of a greenish fluid 
which may be pressed from 
the cut surface of the lungs 
and which may be found in 
the trachea. 

Etiology. — Anything 
which tends to interrupt the 
flow of blood toward the fetus 
through the placenta and 
cord will shut off its oxygen. 
Hence, either compression of 
the cord or premature sepa- 
ration of the placenta is the 
most natural cause of asphyxia. Tetanoid contractions of the uterus in which 
the muscular action is continuous will also arrest the placental circulation. An- 
other condition under which asphyxia may develop is the so-called "vaginal 
birth" which occurs at times in breech presentations. Here the placental 
circulation is interrupted while the head is still in the vagina and remote from 
atmospheric air. There are a number of conditions which favor the development 




Fig. 1018. — Respiratory Organs and Heart of a 
Full-term Child Who Died During Labor of 
Intrauterine Asphyxia from Premature Respi- 
ration Caused by Probable Compression of the 
Umbilical Cord, i, Aspired meconium in the res- 
piratory passages; 2, numerous areas of ecchymoses 
of asphyxia in the heart and lungs. — (Hofmann.) 



AFFECTIONS WHICH ORIGINATE INTRA PARTUM, 



S81 



of asphyxia and which are divisible into maternal and fetal. Such conditions 
do not produce a forcible shutting-off of the oxygen supply, and the mechanism 
by which asphyxia develops in these cases is by no means clear. There occurs 
a suppression in the amount of oxygen which reaches the fetus, either because 
of scarcity of that substance in the maternal blood, or of some anomaly of the 
fetal organs which interferes with the oxygenation of the blood. Hemorrhage 
in the mother, by greatly reducing the number of red corpuscles, and thereby 
interfering with the oxygen supply, becomes a cause of asphyxia. In fetal 
asphyxia from eclampsia the shutting-off of the oxygen supply might be due 
to interference with maternal respiration or to a tetanic condition of the uterus. 
Only after the fetus is born can the various conditions, such as persistence 
of the foramen ovale, atresia of the pulmonary artery, etc., come into play. 
Causes from interference with pulmonary respiration begin to be operative 
before delivery to the extent that 



^| 



the entrance of maternal secretions, 
meconium, etc., into the breathing 
passages may obstruct the first 
efforts at respiration. Persistence 
of the membranes unruptured will 
have the same effect ; likewise the 
fact of so-called vaginal birth (Fig. 
1 019). Again, when the child first 
attempts to breathe by the lungs 
the presence of a disease or malfor- 
mation may be evident for the first 
time; e. g., atresia of the pulmon- 
ary artery, persistence of the fora- 
men ovale, congenital atelectasis. 
An entirely different mechanism 
obtains in asphyxia from brain 
compression. When there are no 
evidences of interference with 
placental circulation through the 
agencies already described, we are 
forced to explain asphyxia due to 
brain compression by the profound 
slowing of the fetal heart which 
diminishes the oxygen received to 
such an extent as to cause death. 

It is claimed that compression of the skull paralyzes the respiratory center. 
Symptoms. — The phenomena known collectively as asphyxia, subaeration, 
oxygen-hunger, etc., however produced, are essentially the same in nature, 
presenting every degree of intensity from mere irregularity and superficiality 
of breathing to a condition of apparent death. Despite this gradation in 
intensity of manifestation, the great majority of authors still cling to the old 
fundamental subdivision of blue and white asphyxia. The former term indicates 
a condition of cyanosis, but differs from the white or anemic variety not so 
much in color as in the behavior of the muscular system, the latter preserving 
its tonus in the blue type, while in the white asphyxia, a state of complete mus- 
cular relaxation exists. Blue asphyxia or cyanosis due to a sudden accumula- 
tion of carbonic acid in the blood is believed to pass naturally into the anemic 
or white stage, which is therefore held to be the terminal manifestation; yet this 
56 




Fig. 1019. — Face of a Newly Born Child 
Covered by a Portion of the Membranes. 
A possible cause of asphyxia in the newly 
born. 



882 THE PATHOLOGY OF THE NEWLY BORN. 

distinction is of little value in practice because in the white variety it is not 
only often possible to resuscitate children thus born, but spontaneous recover}' 
under these circumstances is far from exceptional. I am in favor of doing away 
with the color test or blood test, and of placing the chief reliance upon the 
state of the muscles in determining the degree of subaeration. In mild or 
medium degrees of the latter the pharyngeal reflex is preserved, while in the 
highest degrees it is absent. "Whether or not there is complete concordance be- 
tween the state of the blood and the condition of the musculature does not appear 
to have been determined. When the pharyngeal reflex is absent, the lower 
jaw hangs loose. Another test of extreme asphyxia is found in the failure 
of the heart to respond to the various forms of cutaneous stimulation. The 
blue asphyxia is characterized clinically by a livid redness or blueness of the 
face and upper parts of the body. The face is turgescent and the eyeballs are 
prominent and injected. The muscles of the extremities, neck, and jaws are 
rigid, and the heart action is strong. In children thus born the cord is found 
to pulsate strongly. The reflexes and sphincters behave in a normal manner. 
Children born with blue asphyxia may recover promptly or only after a con- 
siderable interval; or the condition may pass into the white or anemic form. 
Here the condition superficially present in blue asphyxia appears to be inverted. 
The surface is pale instead of livid. The face is pinched, the muscles, includ- 
ing the sphincters, are all relaxed. Circulation is at a standstill, and not only 
is the heart-beat difficult to recognize, but there is no escape of blood when 
the surface is incised. Children born with white asphyxia have a small, almost 
pulseless cord. All in ail, the subject of the symptomatology of asphyxia 
neonatorum is in a most unsatisfactory state. 

Diagnosis. — Diagnosis before delivery is made (i) by the aid of information 
afforded by the fetal heart-sounds, which undergo alterations in quality and 
frequency; (2) by the presence of meconium in the discharges (except in breech 
presentations), and occasionally (3) by the intrauterine cry heard in the lower 
part of the canal or the evidence of respiration in the same locality. Diagnosis 
after deliver}' is made by recognition of the clinical picture of diminution or 
absence of circulatory and respiratory phenomena. In regard to vaginal birth, 
inspiratory efforts of the fetus while the head is in the vagina are betrayed 
by a peculiar quivering of the skull (in head presentations). In this connection 
it should be stated that this phenomenon is equivalent to an indication to 
terminate labor immediately. 

Prognosis. — As long as there is cardiac action there is hope of resuscitation. 
Generally speaking, the prognosis is always grave, varying with the degree 
of asphyxia. Spontaneous efforts at respiration constitute a favorable sign. 
It must be remembered that the failure of respiration ma}- not be owing to 
ordinary asphyxia, but to another affection, such as a trauma affecting the 
respirator}- center, atelectasis, intracranial hemorrhage, etc. If efforts at re- 
animation are successful, the prognosis is still far from favorable, as death 
frequently occurs from atelectasis, paralysis, convulsions, pneumonia, etc. 
Regarding the prognosis in utero, we should not forget that the interruption 
of the placental circulation may be only temporary. The tendency of the 
child to make inspiratory efforts whenever the placental circulation is interfered 
with is not one of self-preservation, for the asphyxia is thereby rendered worse, 
since the blood is forced from the right heart into the lungs. On the other 
hand, the aspiration of amniotic fluid, etc., does no harm, but tends to inhibit 
the respiratory' movements. 



AFFECTIONS WHICH ORIGINATE INTRA PARTUM. 



883 



TREATMENT. 

Prophylaxis. — This includes everything which tends to promote eutocia, 
such as correction of malposition before labor is under way; acceleration of 
delivery by manual compression; correction of positions which threaten im- 
paction; speedy relief of spastic rigidity of the cervix ; preservation of the bag of 
waters; avoidance of abuse of chloroform. Here also belongs the proper man- 
agement of the child after birth. Extreme measures have sometimes been 
recommended or practised for the prevention of asphyxia. Thus, Rapin per- 
formed insufflation of the amniotic sac on a number of occasions. He introduced 

the air by means of a catheter and 
\ syringe, 500 to 600 c.c. at a time. It 

is self-evident that the air could not 
enter the uterine sinuses, protected 
as they were by the amnion. Rapin 
claims good results.* A still more 
radical procedure is the performance 
of tracheotomy when during a breech 






Fig. 1020. — Suspension of the Asphyx- 
iated Newly Born Child by the Feet 
to Assist Gravity in Freeing the 
Air-passages of Foreign Matter. 



Fig. 1021. — Suspension of the Asphyx- 
iated Newly Born Child by the Feet, 
and Clearing the Posterior Pharynx 
of Foreign Matter with the Little 
Finger Wrapped with Gauze. 



delivery the head is arrested at the brim. By means of a tracheal tube the 
lungs may be inflated and respiration begin in this locality. 

Curative Treatment. — Here we have four well-defined indications — namely: 
(1) immediate delivery, the diagnosis of intra-partum asphyxia having been 
made (page 882); (2) removal of foreign substances from the respiratory pas- 
sages immediately upon the birth of the child; (3) the restoration of respiration 
by reflex stimuli, artificial respiration, or insufflation of the lung; (4) treatment 
of shock. 

* "Ann. de gyn. et d'obstet.," Sept., 1899. 



884 THE PATHOLOGY OF THE NEWLY BORN. 

i. Immediate Delivery. — The choice of means will in most cases be in 
favor of the forceps. Often a preliminary bimanual completion of cervical 
dilatation will be demanded. After the expulsion of the child, if cyanosis is 
evident, the cord should be divided at once and allowed to bleed about an 
ounce. It should be remembered, however, that immediate ligation of the cord 
is in itself equivalent to depriving the child of an ounce of blood. In the anemic 
form of asphyxia we should cover the child with hot flannels and wait for the 
pulsations of the cord to cease. 

2. Removal of Foreign Substances from the Air-passages.- — The 
second indication is to cleanse the respiratory passages of fluids aspirated 
during labor. This can be accomplished in part by inverting the child and 
swabbing out its mouth with the little finger wrapped in gauze (Figs. 1020, 1021). 
The contents of the nose should be squeezed out. This cleansing of the mouth 
and nasal passages should be begun as soon as the head is born. Some obstetri- 
cians claim that respiration is the best and most rational means for cleansing 
the lower air-passages. Hence after the preliminaries just described they either 
attempt to excite natural respiration hy reflex stimuli, or in more serious cases 
proceed at once to artificial respiration. Other authorities believe in the ad- 
visability of direct aspiration of the secretions by special devices or by an 
ordinary catheter. This last practice I am accustomed to follow. The same 
apparatus may be used to aspirate the larynx and perform insufflation. All 
attempts, however, to enter the larynx should be frowned upon. Practice upon 




Fig. 1022. — Aspirator for Removing Foreign Matter, as Blood, Mucus, and Meco- 
nium, from the Posterior Pharynx by Suction. 

the cadaver will readily impress one with the barbarousness of such an attempt 
upon the newly born child. The most that can be accomplished by aspiration 
is the removal of mucus from the lower part of the pharynx. A No. 6 catheter 
may be made to answer, into the middle of which I insert a pipette, so that 
its bulbous expansion catches the aspirated fluids which might otherwise enter 
the operator's mouth (Fig. 1022). If a catheter is used, it should be open at 
the end. 

3. Restoration of Respiration. — (1) Reflex Stimuli. — The third indi- 
cation in the treatment of asphyxia is to excite the respirations. There are 
two methods of doing this: viz., reflex stimulation and artificial respiration. 
The former may suffice in mild cases. The usual forms of stimuli applied 
include blowing in the face, slapping the buttocks, sprinkling or immersing, 
hot and cold water being used alternately. The child being nearly immersed 
in warm water, cold water, alcohol, or ether may be dropped from a height 
on the exposed chest. Laborde's method of tongue traction is really a reflex 
stimulus, although usually classified under artificial respiration. Cooke's 
method of dilating the anus with the finger also belongs here. 

(2) Artificial Respiration. — The various methods now in vogue are as follows : 

(a) Byrd's Method. — Dr. Byrd * described a method of artificial respiration 

as follows : " Bring the ulnar sides of the hands together with the palmar surfaces 

looking vertically; then prop them beneath the back of the infant so that the 

*" Baltimore Med. Jour.," 1870, 1, 646. 



AFFECTIONS WHICH ORIGINATE INTRA PARTUM. 885 



extended thumbs may aid as 
extremities. Then, keeping 
to form a fulcrum, the radial 
borders or sides are simul- 
taneously depressed to as 
great an extent as practic- 
able, say 45 degrees, below 
the horizontal line, and then 
gradually elevated or pro- 
nated as many degrees above 
that line, thus facilitating 
the escape of air drawn into 
the lungs during the down- 
ward movement of the head 
and chest. These move- 
ments performed in a regu- 
lar and gentle manner and 
repeated at proper intervals 
seldom fail in the establish- 
ment of respiration where it 
is possible of accomplish- 
ment." Dr. Byrd gives 
three illustrations of this 
method. Byrd's method has 
been somewhat modified in 
the past thirty years, princi- 
pally by Dr. Dew, of New 
York, so that to-day it is 
often performed as follows: 
It should be remembered 
that Byrd's method can be 
carried out with the child in 
a warm bath. The infant 
is grasped with the right 
hand, the neck supported 
between the thumb and the 
index-finger ( Fig. 1023). The 
head is allowed to fall 
backward unrestrained. The 
palm supports the shoulders 
while the three last fingers 
in the axilla lift the arm 
upward and outward. The 
left palm is placed beneath 
the thighs with the fingers 
grasping the knees (Fig. 
1024). Inspiration is induced 
by arching the body of the 
child. The depression of 
the pelvis and lower limbs 
causes descent of the dia- 
phragm through the trac- 



far as possible in sustaining the vertex and inferior 
the ulnar borders of the hands in contact so as 






,' 



. ^ \ 



J 



W\ 






Fig. 1023. — Byrd's Method of Artificial Respira- 
tion. Position for Inspiration. 



fcfe 




Vr 



/ 



0*^ 



Fig. 1024. — Byrd's Method of Artificial Respira- 
tion. Position between Inspiration and Expi- 
ration. 



m! 



H 








Fig. 1025. — Byrd's Method of Artificial Respira- 
tion. Position for Expiration. Note the inver- 
sion of the child to assist in freeing the air-passages. 



886 



THE PATHOLOGY OF THE NEWLY BORN. 



tion upon the abdominal viscera, while flexion at the upper portion of the 
vertebral column elevates the ribs and separates them. Expiration is induced 
by reversing the movements. The hyperextension of the spine is changed to 

extreme flexion (Fig. 1025). The elevation of the 
head and shoulders tends to approximate the ribs, 
while extreme flexion of the thighs crowds the dia- 
phragm upward through the pressure of the abdomi- 
nal viscera. At the completion of expiration the 
child should be inverted, head downward, while an 
assistant clears the mouth and nose of any accumu- 
lated mucus with a gauze- wrapped finger (Fig. 1025). 
Byrd's movements should be repeated six or eight 
times a minute. If properly performed, the air can 
be heard entering the glottis during artificial in- 
spiration, while expiration often results in the ex- 
pulsion of aspirated amniotic fluid and mucus. 

(6) Schultze's Method. — This has been recently 
(1901) described by Schultze himself as follows: 
The child lying upon its back is grasped by the 
shoulders, the open hands having been slipped 
beneath the ■ head. The three last fingers remain 
extended in contact with the back while each index 
is inserted into an axilla, the thumbs lying upon and 
in front of the shoulders (Fig. 1026). When the child 
thus held is allowed to hang suspended, its entire 
weight rests upon the two fingers in the arm-pits. 
It is now swung forward and upward, the opera- 
tor's hands going to the height of his own head, 
the pelvic end of the child rises above its head and 
falls slowly toward the operator by its own weight, 
flexion occurring in the lumbar region (Fig. 1026). 
The thumbs in front of the shoulders compress the 
chest while the hyperflexed lumbar vertebrae and 
pelvis compress the abdomen, and through it the 
thorax; finally, the last three fingers on each side 
compress the thorax laterally. As a result of this 
manceuver when properly done, aspirated secretions 
flow abundantly from the mouth. The distended 
heart also feels the compression, which forces the 
blood into the arteries. The child is now swung 
back into its original position and supported 
entirely by the fingers in the axilla (Fig. 1026). The 
compression of the thumbs and last three fingers is 
removed. The downward swing elevates the ster- 
num and ribs while gravitation and the traction of 
the intestines depress the diaphragm. It is often 
possible to hear the air rush into the infant's glottis 
as it reaches the original position, although this 
can occur in a cadaver. The amplification of the 
thorax lowers the intracardiac pressure. The child should be swung up and 
down ten times for the space of a minute. The effects of the manceuver should 
be as follows: The heart-beat increases in frequency, the cadaveric pallor 




Fig. 1026. — Schultze's 
Swinging Method of 
Artificial Respiration. 
The upper figure is the 
position of expiration and 
the lower that of inspira- 
tion. 



AFFECTIONS WHICH ORIGINATE INTRA PARTUM. 



887 



of the skin becomes replaced by a rosy hue, and the muscular tonus appears. 
The child is then placed in a warm bath and watched. If the inspirations are 
superficial, a momentary dip in cold water is indicated. If the heart action 
becomes poor, the child should be swung again. If prolonged swinging becomes 
necessary, the root of the tongue should be compressed forward in order to 
raise the epiglottis and permit the removal of secretions with the fingers. In 
premature children the thoracic walls are often too soft to benefit by the com- 
pression of the fingers. In these cases insufflation of air should be practised. 

(c) Sylvester's Method (Modified). — This method of artificial respiration re- 
quires an assistant. The child is placed on its back with the head supported 
(not to such an extent that the chin compresses the sternum). The thorax is 
slightly elevated by a towel placed beneath it. The feet are firmly held by 
an assistant with a towel. The physician stands behind the child's head. To 
imitate inspiration the arms are grasped near the elbows 
and brought close together above the head, while at the 
same time gentle upward traction is made. The assistant 
makes counter-traction upon the feet. The movements 
expand the ribs, although the change in the intrathoracic 
pressure may be manifest at first only by retraction of 
the abdomen. If the movements are continued with the 
arms somewhat everted to put the pectoralis major upon 
the stretch, the air gradually begins to enter the chest. 
Expiration is imitated by bringing the elbows down and 
against the sides. The arms are somewhat inverted, 
which brings the forearms across the chest. The opera- 
tor's hands also make compression upon the thorax, so 
that air is forced from the latter, carrying perhaps some 
secretion with it. The movements are made at the rate 
of twenty a minute. The mouth should be wiped out 
from time to time, and if the passages are still clogged 
the child should be inverted and the chest compressed. 
If spontaneous respiration begins, the movements must 
be timed in harmony with it; this is of vital importance. 
When natural respiration is able to replace artificial meas- 
ures, it should be assisted by ordinary reflex stimulation. 
The efficacy of this method is shown by the fact that it 
can maintain the circulation in cases in which the respira- 
tory paralysis is complete. 

(d) Prochownik's Method. — The child is held inverted 

by the legs, the operator's right hand grasping the ankles with the index finger 
between (Fig. 1027). The head is supported below to an extent sufficient to 
produce full extension. Both hands of an assistant compress the thorax 
until all secretions come away. When the hold on the thorax is released, in- 
spiration takes place. After repeating the movements six or eight times the 
child is placed in a hot bath. An advantage of Prochownik's method is that 
it antagonizes the development of aspiration-pneumonia.* 

(e) Labor de's Method. — This consists in exciting the respiratory center by 
rhythmic tractions upon the tongue. The latter is drawn out with the fingers 
(enveloped in a piece of gauze) some fifteen to thirty times a minute. After 
each act of traction it is allowed to fall back into its customary position. It 




Fig. 1027. — Prochow- 
nik's Method of 
Artificial Respi- 
ration. 



* This author's original paper may be consulted in the "Ctbl. f. Gynakol. 
p. 226. 



1894, 



888 



THE PATHOLOGY OF THE NEWLY BORN. 



appears to stimulate the respiratory center through the proximity of the 
latter to some of the other medullary centers which are acted upon by the 
tractions. 

(3) Insufflation. — Opinions as to the utility of this resource are of great 
variance. Some mention it as the first, others as the last resort. It may be 
practised with or without instruments. The former comprise special tracheal 
tubes which are difficult of introduction, and apparatus designed to cover 
the nose and mouth of the child. An ordinary stethoscope will answer the 
latter purpose. If a tube is used, it should be introduced by the aid of a finger 
which has previously located the arytenoid cartilages. If the tube enters the 
esophagus, insufflation will inflate the belly. In insufflation without instru- 
ments — the mouth-to-mouth method — the child lies supine with chest elevated, 
as in Sylvester's method of artificial respiration. The operator breathes into 
the mouth through gauze; the thorax should be compressed gently after each 
insufflation. 

(4) Shock Treatment. — The fact that measures that belong under this 

head are of such value in asphyxia 
apparently justifies the theory that 
the condition itself possesses a con- 
siderable element of shock. These 
measures comprise the application of 
heat, either dry or moist, the child 
being wrapped in hot flannels or im- 
mersed in hot water; hot saline in- 
fusion into the rectum; hypodermics 
of brandy (five or six drops) or of 
strychnin (2^0 grain). 

(5) Umbilical Infusion. — Suc- 
cess has attended infusion through 
the umbilical vein after all the cus- 
tomary resources have proved ineffi- 
cient.* The infusion is something 
more than an ordinary saline solu- 
tion, for Schucking added fructosate 
of soda, a substance which is believed 
to take up the excess of carbonic 
acid in the blood with the formation 
of sodium carbonate and sugar. The 
formula used is as follows: Fructosate 
of soda, 0.5; sodium chloride, 0.7; 
boiled water, 50 c.c. The apparatus employed is a graduated bottle, a tube, 
and a cannula (Fig. 1028). The umbilical vein is cut across and the cannula 
inserted. Thirty cubic centimeters are thrown in at first, followed by a second 
infusion of 20 c.c. As soon as the heart and respiration start up, ordinary 
measures are resumed. 

Resume.— (1) In premature and feeble children Byrd's method of artificial 
respiration should be practised, with the child immersed in hot water or between 
hot flannels. Insufflation should be practised by the mouth-to-mouth method 
or by catheter. (2) In the apoplectic or livid form Byrd's method should be 
used, varied with a few swings a la Schultze. Lest the surface become chilled 
from exposure, the child should then be placed immediately in hot water. 
* Schucking: "Ctbl. f. Gynakol.," June 7, 1902. 







Fig. 1028. — Method of Infusing Saline 
Solution into the Umbilical Vein of 
the Newly Born for Some Varieties 
of Asphyxia. 



AFFECTIONS WHICH ORIGINATE INTRA PARTUM. 

(3) In the anemic or pallid form Sylvester's or Byrd's method should be used, 
with the child between hot flannels. 



2. FETAL TRAUMATISMS OF BIRTH. 

1. Traumatisms of the Brain and Cord. — Injuries to the skull and brain 
are due to obstructed labor, to the faulty application of the forceps, or to 
faulty extraction of the after-coming head. The lesions which are thus brought 
about comprise simple compression of the brain without hemorrhage (one of 
the chief factors in the production of intra-partum asphyxia) and intracranial 
hemorrhage, which is nearly always meningeal. Naturally the results of com- 
pression often coincide with hemorrhage, so that to asphyxia are conjoined the 
consequences of effusion of blood within the cranium. 

Cerebral Apoplexy. — When the blood is extravasated upon the surface 
of the brain or between the meninges, the term meningeal apoplexy is used; 
if in the substance of the brain, cerebral apoplexy. No small number of infant 
deaths either during or closely following the act of parturition are referred to 
intracranial hemorrhage. Etiology: Some few cases are due to syphilis, and in 
early hemorrhages the exact nature of which has not been definitely determined 
direct injury, a blow or a fall in the later months of pregnancy, and the accidents 
of precipitate labor have been responsible for others; but the great majority are 
in some manner connected with tedious labor, whether as a result of breech, 
transverse, or brow presentation, contracted pelvis, insufficient uterine power, 
version, the too early rupture of the membranes, or fetal abnormalities. The 
injudicious and indiscriminate use of the forceps is a potent factor. Pathology: 
Within the skull there is no zone of freedom from hemorrhage ; it may be epidural 
or subdural, within the meninges or in the brain substance itself. It occurs 
at the vertex or base, and varies in amount from very small extravasations 
to those which cover the entire brain substance. In early life meningeal hemor- 
rhage is much more common than the cerebral variety and basal hemorrhages 
greatly outnumber those of the convexity. The most common seat is beneath 
the pia mater, less frequently into the cavity of the arachnoid, the blood escaping 
in these situations and spreading uniformly in all directions. External collec- 
tions of blood may exert so decided a pressure upon the surrounding parts 
that the results of increased tension are at once recognized when the skull is 
opened. The meninges corresponding to the extravasation may be normal or 
congested to a greater or less extent. In the cerebral form — hemorrhage within 
the brain substance — the blood. escapes from numerous points without causing 
laceration or injury to the surrounding parts. The blood-clots are almost always 
dark-colored; later on they change to a chocolate or brownish-yellow color. 
Hemorrhage into the ventricles of the brain sometimes occurs and bleeding into 
the stomach, intestines, abdominal organs, and lungs is not infrequent. Symptoms: 
The symptoms agree quite closely with the pathological conditions just described. 
They are more uniform, but varv according to the seat as well as the quantity 
of the effused blood. When due to the ordinary causes of protracted labor, 
the infant is born apparently dead, resuscitation is gradual and difficult, the 
cry is feeble, the eves are motionless, and the extremities are limp and 
flaccid. The face is livid or pallid and the respirations are gasping. By means 
of hot and cold baths, artificial respiration, friction, the general condition of 
the infants may show slight improvement, but ordinarily they succumb after 
living a few hours or a few days. Depending upon the distribution of the 



890 



THE PATHOLOGY OF THE NEWLY BORN. 




Fig. 



V 



1029. — Facial 
the Newly 



Paralysis of 
Born. 



blood-clots and the amount of intracranial pressure, various degrees of 
paralyses of the face, arms, and legs may occur, and convulsions and rigidity 
of the entire body are often present. In the cases which survive the early 
days of life the rigidity of the trunk and extremities may persist and the degrees 
of paralysis may be definitely determined. In favorable cases the improvement 

goes on more or less slowly and scarcely ever 
becomes more than partial. Contractures and 
other deformities from the permanently para- 
lyzed muscles are sequelae of frequent occur- 
rence. Prognosis: If the infant survives, the 
smaller extravasations are gradually absorbed 
and the surrounding parts tend to assume their 
^Pfcfc. . j,J normal functions. Extensive hemorrhage is 

usually fatal. As a rule, the prognosis de- 
pends on the severity of the early symptoms ; 
the deeper the unconsciousness and the more 
deficient the respirations and pulse, the less 
the prospect of recovery. Many cases of epi- 
lepsy and idiocy can be traced to a probable 
hemorrhage in the brain occurring during or 
after a prolonged or an instrumental labor. In other and rare cases recovery is 
to all appearances complete. Treatment: In view of the fact that prolonged 
labor is responsible for the majority of cases, the indications for treatment are 
almost wholly preventive. Impacted infants should be delivered with all possible 
despatch. Forceps and other operative 
measures must be employed with judg- 
ment, brain pressure being avoided as 
much as possible, remembering that dur- 
ing the progress of labor a child about 
to be born is made up of a mass of deli- 
cate organs and tissues incapable of re- 
sisting unnecessary force. Asphyxia de- 
mands immediate and persistent efforts 
to inflate the lungs fully. Subsequently 
any remedial methods can be instituted 
only in accordance with individual 
symptoms. 

2. Injuries to Nerve-trunks. — (a) 
Facial Paralysis. — Traumatic facial 
paralysis is usually due to compression 
of the nerve by the forceps at or near 
the stylomastoid foramen, but may 
sometimes occur in spontaneous delivery 
(Fig. 1029). In forceps accidents only 
one or more of the branches of the nerve 
may be injured, so that only a portion of 
the distribution of the nerve may be 

paralyzed (most frequently the temporofacial branch). Forceps paralysis is 
chiefly unilateral, because only one side of the face is exposed to the instru- 
ment. Spontaneous facial paralysis : The subject of forceps paralysis is a 
relatively simple one, but it is otherwise with the facial paralysis of spontaneous 
delivery. This accident is of rare occurrence, and not more than a dozen cases 








Fig. 1030. — Facial 
Pressure of a 
(Ahlfeld). 



Paralysis Due to 
Forceps Blade. — 



AFFECTIONS WHICH ORIGINATE INTRA PARTUM. 891 

were upon record up to the year 1900. These cases have been collected and 
analyzed by Vogel.* 

Etiology. — This accident cannot be regarded as a definite lesion in which 
certain causes determine a constant result. Hardly any two of the cases are 
alike. In two cases reported as traumatic facial paralysis no peripheral injury 
could be found, while the coexistence of hypoglossal paralysis made it highly 
probable that the mischief was in reality of central origin, perhaps from a 
minute hemorrhage. This accident is most likely to occur in contracted pelves. 
In one case it was apparent that over-rotation of the shoulders had produced 
a rupture of the sternomastoid muscle with resulting hematoma, and that 
the situation of the latter enabled it to compress the facial nerve. The paralysis 
disappeared as soon as the hematoma was absorbed. Quite another mechanism 
is shown in a case observed by Knapp, of Prague. The pelvis was of the justo- 
minor type and a dent had been caused on the left side of the frontal bone. 
Around this indentation a notable degree of oedema had formed, extending 
very close to the external auditory meatus. This oedema was sufficient, appa- 
rently, to compress the facial nerve and cause temporary paralysis. Olshausen, 
who had seen two cases of facial paralysis after spontaneous delivery, was 
unable to find any evidence of peripheral trauma, and could explain the accident 
only by the hypothesis of amniotic adhesions with the skin. In a case reported 
by Geyl there was a congenital malformation of the ear of the paralyzed side, 
suggesting the possible correctness of Olshausen's theory. In Ludwig's case 
every known element was apparently excluded and the author could only 
surmise the existence of a violent stretching of the facial nerve. The pelvis 
was of the flat rachitic variety and the fetal head had presented frontally. 
In a case reported by Dancher the labor was precipitate, so that the nerve 
may have been forcibly stretched. In one of Vogel's cases the pelvis was 
narrow, there was an exostosis of the symphysis, the presentation was frontal, 
and the labor was protracted. The opposite parietal bone was flattened. 
There was overriding of the right parietal by the left, but there were no evidences 
of hematoma or amniotic adhesions. In Vogel's second case the conditions 
were almost precisely the same. It could be shown that the small exostosis 
behind the symphysis corresponded exactly with the site of the stylomastoid 
foramen; during labor the right ear could be felt above the symphysis. 

Symptoms. — However produced, — i. e., whether instrumental or spontaneous, 
— facial paralysis may be apparent immediately after birth or only after an 
interval of one or two days. It has never been known to become worse after 
its establishment. When in repose, the only symptom noted may be the open 
eye of the affected side, a result of the paralysis of the orbicularis. When the 
child cries, however, the whole side of the face is seen to be smooth, while the 
mouth is drawn toward the opposite side. 

Prognosis. — The course of this affection is essentially benign, tending to 
spontaneous recovery after a few days or weeks, especially in non-instrumental 
cases. In case of extreme injury by the forceps a much longer interval may 
be required for recovery, and in a few rare instances the nerve has been injured 
too severely to permit of recovery. Under these circumstances the reaction of 
degeneration occurs and the muscles undergo atrophy. 

Diagnosis. — In diagnosis, care must be taken to exclude the possibiilty of 
a facial monoplegia of central origin. In cases of this sort (due to small intra- 
cranial hemorrhages) only the lower part of the face is involved. Despite the 
benign character of this affection, our prognosis must be guarded, in view 
of the fact that permanent paralysis has been known to occur. 

* " Monatschrift f. Geburtshulfe und Gynakologie," vol. xn. 



892 THE PATHOLOGY OF THE NEWLY BORN. 

Treatment. — There is nothing to be done for this affection during the first 
week or two except to protect the exposed eyeball. If spontaneous improve- 
ment sets in after the tenth day, a hopeful prognosis may be given. Should 
recovery be delayed, we should begin to faradize the affected muscles. If there 
is no response to this current, galvanism should be substituted, with mild counter- 
irritation. This treatment should be continued, if necessary, for months. 

(6) Arm Paralysis. — These accidents are of rare occurrence, most of 
the recorded cases having been reported by neurologists. A careful analysis 
of all the published cases by Stolper * appears to show that a radical distinction 
exists between the arm paralyses which accompany head presentations and 
those which are associated with anomalous presentations of the fetus. The 
latter appear to be simple in their nature and readily comprehensible, while 
the former are complex and difficult of explanation. Birth paralysis, so called, 
is seated in some portion of the brachial plexus, especially that corresponding 
to the fifth and sixth cervical nerves. 
Etiology: In regard to the etiology of 








-* 



Fig. 1031. — Depression in Left Parietal Fig. 1032.- — Traumatic Depression of the 
Bone. Right Parietal Bone. — (Ahlfeld). 

this affection, Fieux has recently claimed that it is due necessarily to lateral 
inclination of the head,t his claim being founded upon numerous experiments. 
Shoemaker has since gone over the same field of study, + and claims that there 
are at least three other causal agencies: viz., the mere pressure of the fingers 
while practising the M auric eau manceuver, the terminal phalanges being strongly 
bent ; the pressure of the clavicle ; and, finally, forcipressure itself. The lesion of 
the nerves which is responsible for the paralysis of the upper extremity is due 
to direct compression as well as to the stretching incidental to latero-flexion 
of the head toward the opposite side. Doubtless other manipulations incidental 
to freeing the arm, delivery of the shoulder, etc., are able to produce the same 
condition, either by compression or stretching. That the compression must 
always be made at so circumscribed an area as "Erb's point" seems hardly 
reasonable. While this form of paralysis occurs alone, it naturally compli- 

* " Monatschrift f. Geburtshiilfe und Gynakologie," xvi, 1. 

t " Annales de Gynecol.," 1897, 1. J " Zeit. f. Geb. u. Gynak.," Bd. xli. 



AFFECTIONS WHICH ORIGINATE INTRA PARTUM. 893 

cates more severe injuries, such as fractures. Kustner, one of the few obstet- 
ricians who have exhaustively studied this subject, cannot conceive that a 
simple paralysis from compression could become permanent; he therefore is 
inclined to credit the theory that at the time of the accident some fracture, 
dislocation, or diastasis of the head of the humerus occurred, and such an injury 
might readily escape observation. As a matter of fact, Kustner has found 
evidence of such a bone lesion in all of the worst cases of birth paralyses. Stol- 
per's study has led him to the conclusion that the forceps can cause obstetrical 
paralysis only in incomplete flexion of the head, with non-recognition of the 
position or malapposition of the forceps. Paralysis from clavicular pressure is 
possible if an arm with its clavicle is elevated strongly upward and backward. 
In cranial positions the paralysis may arise from stretching of the fifth and 
sixth nerves as a result of strong traction in delivering the shoulders, the head 
at the same time being considerably inclined. Strong traction in incomplete 
head flexion also favors paralysis. In paralysis associated with other than 
head presentations, the cause appears to be the pressure of the clavicle, or 
too strong traction upon a head, especially when the latter is inclined to one 
side and extended backward. Prognosis: This must be regarded as dubious, 
depending chiefly upon the etiology. It is doubtless best when the condition is 
due to simple forceps pressure ; when due to clavicular pressure, the prognosis is 
almost uniformly bad. If due to traction, the stronger the latter, the greater the 
lesion and the worse the prognosis. In spontaneous delivery paralysis has been 
found to be much less severe with the woman in the dorsal position, lying 
lengthwise with the bed or an operating table. Aside from the cause, prognosis 
is also based on the electrical reaction of the muscles in respect to the presence 
or absence of the reaction of degeneration. Treatment: This comprises massage, 
mild counterirritation, and electricity. 

3. Injuries to the Cranial Bones. — These comprise (a) depressions, (b) frac- 
tures. 

(a) Depressions or Indentations. — The occurrence of depressions or 
indentations in the fetal cranial bones does not imply the existence of a de- 
pressed fracture, although the latter might also be present. These lesions are 
very infrequent occurrences — according to Ahlfeld, not over once in three hun- 
dred living births. Etiology: They are due to some disproportion between the 
fetal cranium and the maternal pelvis when the latter is contracted, the im- 
pression being made by the sacral promontory, for example; or to the forceps, 
or even to the finger of the accoucheur. These impressions have usually the 
dimensions of the imprint of a man's thumb in wax (Fig. 1033). They are chiefly 
encountered in children born alive and the latter generally survive. Prognosis: 
The lesion is quite likely to rectify itself spontaneously, either wholly or in part, 
but in case it persists through life it has seldom been known to give rise to any 
intracranial mischief. Treatment: It has been proposed to trephine in cases in 
which paralysis appears to be due to this injury. I have seen good results in 
one case. With this possible exception, there is hardly any treatment for 
impressions of the skull. It is claimed that the application of dry cups is 
sufficient to correct the deformity, which, however, had better be left to itself. 

(b) Fractures. — These have also been noted after both spontaneous and 
artificially aided delivery under the same circumstances which give rise to 
indentations, although cases have been placed on record in which both the 
pelvis and the fetus were quite normal, and the only possible source of violence 
was the uterine contraction, possibly excited by the use of ergot. The 
parietal is said to be the bone most frequently fractured, but this was not the 
case in the statistics collected by Lomer. Any one of the cranial bones may 



894 



THE PATHOLOGY OF THE NEWLY BORN. 



X 



be involved. Rupture of the sutures and detachment of some one of the bones 
may take place under the same circumstances. If fracture of a bone or rupture 
of a suture should be complicated by the laceration of a sinus or large blood- 
vessel, fatal hemorrhage will result. Minor degrees of hemorrhage from rupture 

of small vessels or some lesion of the 
^gjgfjjg |J|^ substance of the brain may also com- 

plicate these fractures. As in the case 
of trauma of the bones of the adult 
skull, we must bear in mind the possi- 
bility of remote consequences. 

Facial Bones. — Fracture of. the bones 
which make up the orbit is of occa- 
sional occurrence, as are likewise frac- 
tures of the lower jaw and diastasis of 
its symphysis. Fracture into the orbit 
— usually through the frontal bone — is 
followed by exophthalmus, yet this 
latter phenomenon has also been noted 
after simple application of the forceps 
over the temporal region without the 
production of trauma. Rupture of 
the bulbus oculi and other intraorbital 
lesions may complicate fracture into the orbit. While the latter form of injury 
is ascribed chiefly to the use of forceps, all the phenomena thus produced, 
including rupture of the globe, have been noted in spontaneous delivery; while, 
on the other hand, experimental fracture on the cadaver into the orbital cavity 




Fig. 1033. — Depression in the Right 
Parietal Bone Caused by the Faulty 
Application of the Forceps. — {Authors 
collection of fetal skulls.) 




Fig. 1034, — Contusion and Sloughing of the Scalp Caused by a 

Pelvis.— (Ahlfeld). 



Contracted 



by means of the application of forceps I have found to be an impossibility. 
It is therefore evident that the rationale of these orbital injuries is not wholly 
clear. Fractures of the lower jaw occur, as a rule, from traction on the after- 
coming head in breech presentations. 



AFFECTIONS WHICH ORIGINATE INTRA PARTUM. 



895 



4. Fractures of the Long Bones. — As a rule, the violence exerted in connec- 
tion with dystocia and its management tends to produce diastasis rather than 
fracture, provided that the long bones of the fetus are healthy. When for any 
reason (fetal rickets) these structures are brittle, very slight manipulation may 
produce a fracture. But Ballantyne records the case of a fracture of the shaft 
of the thigh in a healthy child during normal delivery. There were no evidences 
of fetal rickets or prematurity. Apparently spontaneous fractures, whether in 
the healthy or otherwise, cannot justly be put down as examples of birth- 
trauma. If recognized, fractures and diastases may readily be healed. 

Dislocations. — The luxations which are occasionally present at birth are 
believed to be due in most instances to malformations of the joints. (See 
Congenital Dislocation of the Hip.) The possibility of arrested development 
of the joint in these cases tends to invalidate the notion that luxation occurs 
as a pure birth traumatism, despite its general plausibility. 

5. Injuries to the Scalp. — Among those I include (1) the caput succedaneum 
and (2) cephalhematoma, together with ordinary lacerated and contused (3) 
wounds and (4) sloughs. 

(a) Caput Succedaneum. — The caput succedaneum, otherwise known as 
"false cephalhematoma," occurs with 

such frequency as to be almost phys- Blood between 

iological, the location varying with 
the position of the child's head during 
delivery. This condition is a phe- 
nomenon of labor itself as well as 
an affection of the newly born child, 



BONE 

PERIOSTEUM 



Skin 

Subcutaneous Tissue 
Periosteum 
Bone 





Fig. 1035. — Caput Succedaneum. 



Fig. 1036. — Cephalhematoma. 



and is a subcutaneous, serous infiltration of that portion of the presenting 
part corresponding to the center of the birth canal (Fig. 1035). As the pre- 
senting part is forced through the os uteri or the vulva, it escapes the com- 
pression to which the surrounding tissues are being subjected, with the result 
that in this free area a sero-sanguineous effusion occurs, since the constric- 
tion about the presenting part interferes with the circulation. As a rule, 
this swelling does not form until after the membranes have been ruptured and 
frequently it may not form at all, as in cases in which delivery occurs very 
rapidly, or if the maternal parts are disproportionately large. While a certain 
amount of blood is present in the effused liquid, actual hemorrhage is rare. 
The caput succedaneum varies considerably in size and shape. It may be 
rounded, oval, or elongated, and varies in its long diameter from less than one 
inch (2.54 cm.) up to three inches (7.62 cm.). The skin over the caput is con- 
gested, and if the labor has been unusually long, it may present a purplish hue. 
As the presenting part must traverse several obstacles to its egress, the caput 




896 THE PATHOLOGY OF THE NEWLY BORN. 

succedaneum may be formed within the uterus, within the pelvic canal, or 
at the vulval orifice, and it is not uncommon for a primary swelling to develop 
when the head passes the os and a secondary caput to form concentrically at 
a point farther down, especially at the vulval orifice. If there is narrowing 
within the resisting bony canal of the pelvis, the caput may be of extreme 
dimensions and may be born before the head has traversed the superior strait. 
(Compare Vertex, Part IV, and Face, Breech, and Shoulder Presentations, 
Part V.) 

(b) Cephalhematoma. — In this affection the escape of blood is between 

the periosteum and bone, while in caput 
succedaneum the site of the effusion is sub- 
cutaneous. The extravasated liquid consists 
wholly of blood (Fig. 1036). Site: The swell- 
ing is usually over a parietal bone and limited 
by some of the sutures. Occasionally it trans- 
gresses the sagittal suture and lies over both 
parietals. The right side of the head is the 
more commonly affected. Location of the 
tumor over the other cranial bones occurs 
infrequently. Symptoms; Cephalhematoma 
is seldom present at birth but appears two 
or three days later. The superjacent skin 
is not discolored. The tumor may be of any 
1 size up to that of an apple. Fluctuation is 
present; the limitation of the mass by 
sutures gives it a bony outline. This affec- 
tion must not be confounded with trau- 
W matic hemorrhage in the same locality which 
occurs occasionally as a result of forceps 
delivery. Here the swelling is diffuse and 
is not limited by the sutures. Frequency: 
The frequency with which cephalhematoma 
occurs is stated by different authors to be 
about once in two hundred labors. Course: 
The cause of this affection is obscure and 
the factors which obtain in caput succeda- 

Fig. 1037.— Caput Succedaneum. neum are not in evidence here. It has even 

. of Left Parietal Bone Seen' been found in breech presentations. The 

from Behind Note also the course { on the whole, benign, and the 

lateral flexion of the fetal body. '. ,--... ~ „. 

Compare Fig. 580.— (From Dr. W. tendency is to self-limitation. The swelling 

■ I E. Studdiford's frozen section at usually persists for a month or more. Occa- 

- the E ™^y Hospital) ^^ infection of the b l ood . clots occurs 

and perhaps caries of the bone. Diagnosis: 
Cephalhematoma appears several days after birth as a bloody tumor under- 
neath the pericranium, generally on the side of the head, and, as a rule, is 
due to pressure. Caput succedaneum is present at birth as a serous infiltra- 
tion in the tissues over the pericranium and over the presenting part and is 
due to lack of pressure. It is soft but does not fluctuate. Cephalhema- 
toma has a soft, cystic feel, but later becomes crepitant. It exists for one or 
two weeks and sometimes breaks down and suppurates. Caput succedaneum 
lasts only two or three days, after which it disappears. Besides these two 
forms of tumor found on the head of the newly born child several others may 




AFFECTIONS WHICH ORIGINATE INTRA PARTUM. 



897 



be mentioned, the possibility of the existence of which at times complicates 
the diagnosis, viz.: hernias cerebri, vascular tumors, meningocele, encephalo- 
cele, and hydrencephalocele. These abnormalities have been noted elsewhere. 
(See page 275.) Meningocele consists of a tumor of the scalp partly formed 
by the meninges; encephalocele is made up partly of brain substance; while 
hydrencephalocele contains in addition a little liquid. (See page 275.) Treat- 
ment: Absorption of the extravasated blood may be hastened by the use locally 
of iodine, and by compression. It is not advisable to open the cavity unless 
an abscess forms. The blood might possibly be aspirated to relieve the dangerous 
tension of the scalp and pressure on the skull. In many cephalhematomata 
seen in hospital and private practice, in only one was an incision demanded; in 
this case, in private practice, a child of a primipara with a generally contracted 
pelvis after a thirty-six-hour labor and a difficult forceps extraction developed an 
enormous blood tumor. The tumor showed signs of sloughing and was freely 





Fig. 1038. — Double Cephalhematoma. 



Fig. 1039. — Single Cephalhematoma. 



incised, the fluid blood washed out with saline solution, and a gauze drain 
inserted. A rather tedious recovery resulted. 

6. Hematoma of the Sternomastoid ; Caput Obstipum. — Traumatic hemor- 
rhage intra partum into the substance of the sternomastoid of one or both sides 
has been noted in connection with both forceps and breech deliveries and after 
over-rotation. The extravasated blood sets up a myositis, and in time the 
phenomenon known as wryneck or caput obstipum may result. This hypothesis 
as to the origin of the deformity, however, is repudiated by many, but there is 
no doubt that the patient may have a transitory wryneck. The blood is ab- 
sorbed in the course of several months, and in many cases is known to leave 
no deformity behind. This lesion may readily be mistaken for an enlarged 
lymph-node, being most commonly about the size and shape of a pigeon's 
egg. No treatment is required, least of all surgical intervention. 

7. Aspiration Pneumonia. — The records of autopsies upon the newly born 
appear to show that a certain number of deaths are due to catarrhal pneumonia 
which develops within two davs after delivery. There is no evidence to show 

57 



898 THE PATHOLOGY OF THE NEWLY BORN. 

that this condition can originate ante partum, nor that it ever arises from atelec- 
tasis or infection. On the other hand, there is little doubt that it is due to no 
other cause than the irritating effects of aspirated amniotic fluid which was 
sterile at the time of the accident. This aspiration indicates that the fetus 
has attempted to respire in utero during the act of labor as a result of temporary- 
oxygen hunger. The aspirated fluids do not appear to produce the pneumonic 
state at the time of occurrence, for the child is usually healthy at birth, and 
perhaps for some time afterward. The supervention of the disease is then 
announced by rapid respiration, cyanosis, fever, and cough. Death probably 
occurs as a rule, although percentages are wanting. It is known that recovery 
is possible and that the child may be free from symptoms in the course of a 
week or ten days. Diagnosis: This is attended with great difficulty. . Aspira- 
tion pneumonia has not been recognized as a clinical entity until recently. 
Itjwill be necessary to exclude a number of other conditions, which would be 
almost impossible without autopsy. If the child is of normal development, 
without evidences of septic infection, and especially if there is a history of 
dystocia with evidences of temporary intra-partum asphyxia, the presence of 
the symptoms just narrated will make the diagnosis of aspiration pneumonia 
very probable. Treatment: The infant, since it cannot nurse, must be fed by 
stomach-tube or medicine-dropper, and must receive stimulants. The general 
management corresponds largely to that of similar cases in older children. 



4. INTRA-PARTUM INFECTION. 

i. Ophthalmia Neonatorum. — This term is applied to a form of acute con- 
junctivitis occurring in infants and first manifesting itself within a period of 
from two to five days of birth. It has been customary to describe at least 
two varieties of the disease: (i) one of which, of no great importance, may be 
called catarrhal, and (2) the other, purulent, fraught with the greatest danger 
of serious injury to the eye, the cornea, and consequently to sight. 

Etiology. — (1) A mild or a moderate catarrhal ophthalmia in an infant 
may be caused by any non-specific irritant, such as ordinary vaginal secretion, 
the use of soap or antiseptics, too much exposure to strong light, and also the 
prophylactic use of antiseptics in the conjunctival sac, notably silver nitrate. 
(2) The exciting cause of the second variety of the disease is infection, and infec- 
tion with the gonococcus alone or mixed with other pathogenic microorgan- 
isms which have reached the eyes, during or immediately after parturition, 
from the maternal passages or from the hands or instruments of the physician. 
There is now no doubt of the causative relation of the gonococcus, which has 
been proved by numerous experiments both by culture and by inoculation. 
It is possible that the infection sometimes occurs when the eyes are first washed 
and not during parturition, and it is, of course, possible to infect the eyes of 
an infant with the gonorrheal virus in the same ways that the eyes of an adult 
are infected, but this would not be strictly ophthalmia neonatorum and might 
occur at any time. In the milder cases the gonococcus is not found and the 
condition must be attributed to infection with other pyogenic germs. The 
proportion of cases in which the gonococcus is found has been estimated at 
about 36 per cent. (Bartley). 

Symptoms. — (1) Catarrhal ophthalmia could be dismissed in a very few 
words were it not for the fact that many of the specific cases are, in the begin- 
ning, deceptively like those belonging to the mild category, so that it is safer 



AFFECTIONS WHICH ORIGINATE INTRA PARTUM. 899 

to regard all with suspicion and treat them like commencing purulent cases. 
In those cases which are really catarrhal the inner surface of the lids is congested 
and red and there is a serous or sero-mucous discharge, but the lids are not 
swollen and there is no tendency for the symptoms to get worse rapidly. Patho- 
logically, the condition is one of acute, non-specific, catarrhal inflammation, 
and it tends to subside without causing structural change or necrosis in the 
mucous membrane. Bacteria may sometimes be present, but never the gonococ- 
cus. The symptoms are rarely severe and usually yield promptly to treatment. 
(2) The symptoms of purulent ophthalmia appear, as a rule, on the third 
day after birth, sometimes a little later, unless the infection has occurred after 
delivery, when they appear at any time. The first signs are redness and oedema 
of the lids, the latter increasing so much that it becomes difficult for the nurse 
to separate the lids. The conjunctiva of the lids becomes very greatly swollen 
and congested, and has a granular or uneven surface, due to the great exudation 
of inflammatory products into the loose connective tissue. Very soon the con- 
junctiva of the eyeball itself is involved and becomes swollen in the same way, 
a condition called chemosis, and the cornea appears to be at the bottom of 
a cavity formed by the swollen edges of this ocular conjunctiva. The discharge 
at this stage is serous, or more often sero-sanguinolent. In very severe cases 
the exudate may be so great that the conjunctival vessels are compressed and 
the conjunctiva, instead of appearing red, looks grayish or yellowish-pink. A 
very free secretion of pus soon begins and the intense swelling and oedema may 
diminish to a certain extent. The pus may flow freely from the palpebral 
fissure, or the edges of the lids may adhere to each other, thus allowing the 
conjunctival sac to be ballooned out by the accumulation of the secretion. 
This stage of the disease is the most dangerous for the nurses and attendants, 
and the condition just described should be specially guarded against, since the 
pus is under considerable tension and may fly into the faces of the by-standers 
when it is suddenly released by the partial or complete separation of the lids. 
The most serious complication -which may occur in the disease is involvement 
of the cornea, more often observed in adults, but still common enough in infants. 
Destruction of this membrane of course means blindness, and it is estimated 
that at least 20 per cent, of all the blindness in the world is due to involvement 
of the cornea in this form of ophthalmia. The severer the infection, of course, 
the greater the danger of damage in this respect. The first sign of impending 
trouble is an appearance of dullness and cloudiness of the whole or a part of 
the corneal surface. The cloudy patches soon become distinct gray areas of 
infiltration which later turn yellow and ulcerate. The ulcers may perforate 
into the anterior chamber or they may spread without perforation, the former 
being the course with the best prognosis. If there is marginal infiltration 
around the whole cornea, the so-called annular abscess is very likely to result, 
and in that event the cornea will be destroyed, with perhaps pan -ophthalmitis 
later. This means loss of the eye. In general, it may be said that the more 
pronounced the chemosis, the greater the danger that the cornea will be involved 
in the infectious process. Fortunately in infants, with proper measures, the 
danger of serious damage is not great. When the disease progresses favorably, 
the swelling, redness, and purulent discharge gradually diminish, and finally 
the lids reach a normal condition, though several weeks may be required for 
this. In infants there is rarely any tendency for the inflammation to persist 
and become chronic. A febrile movement is often present and evidences of 
systemic gonococcus infection may occur; acute inflammation of the joints has 
been observed. 



900 THE PATHOLOGY OF THE NEWLY BORN. 

Diagnosis. — This should present no difficulties except in the beginning 
of the attack, and in doubtful cases it is wise to be upon the safe side and treat 
the case as one of specific ophthalmia. The profuse purulent secretion and 
swelling of the lids are characteristic. The history of the mother may be of 
assistance, and an attempt should be made to confirm the diagnosis by micro- 
scopic examination of both maternal and fetal secretions. 

Prognosis. — In a large proportion of the cases that do not receive prompt and 
intelligent treatment the sight is destroyed. It has been estimated before the 
general adoption of prophylactic measures that from 26 to 30 per cent, of 
all the cases of total blindness in adults was the result of purulent ophthalmia 
of the newly born. 

Treatment. — (1) Catarrhal: The treatment of catarrhal conjunctivitis con- 
sists in cleanliness and protection from light. A solution of borate of sodium, 
ten grains to the ounce of camphor water, or a solution of boric acid, may be 
used frequently as an eye-wash, and it is a good plan to keep the edges of the 
lids from adhering by using a little boric -acid ointment upon them. The eyelids 
must be kept free from dried secretions by some such means, and it is better 
to make the manipulations at regular intervals, longer or shorter as the case 
is mild or severe, so that the child will rest without being interfered with need- 
lessly. The condition is one which, as a rule, responds very promptly to treat- 
ment. (2) Purulent: The treatment of purulent ophthalmia neonatorum re- 
solves itself into two parts: namely, (1) prophylactic and (2) curative. 

(1) Prophylaxis. — What is as important in this matter as treatment is prophy- 
laxis, and no measure should be neglected which can assist in preventing the 
occurrence of the disease. When the maternal passages are suspected, a pre- 
liminary course of antiseptic treatment should be instituted, beginning about 
two weeks before delivery. This should consist in daily or twice daily vaginal 
douching, first with a mild alkaline solution and then with one of bichloride 
of mercury, strength 1 : 5000. Just before delivery something must be done 
to provide a substitute for the normal lubricating mucus which will have been 
washed away by the douching process, and a 1 per cent, lysol solution will be 
found useful for this purpose. The vagina may be washed out with it when 
labor begins. As soon as the child is born its face must be carefully washed, 
special attention being given to the eyes, and even when infection is not suspected 
one or two drops of a 2 per cent, silver- nitrate solution should be dropped into 
each conjunctival sac. This may be washed away in a moment or two with 
salt solution if desired. It has now become with most obstetricians in maternity 
service a matter of routine practice to use this 2 per cent, solution in the eyes 
of all infants, and since the method was introduced the number of cases of 
ophthalmia neonatorum has decreased enormously. As an illustration, we 
may cite the experience of Crede, who suggested the method. At his Lying- 
in Asylum, at Leipsic, before the -use of silver nitrate, this form of ophthalmia 
occurred in 10.8 per cent, of all infants; after the treatment was systematically 
carried out the percentage fell to 0.1 or 0.2 per cent. Other similar experiences 
have been reported. The methods of procedure will almost invariably cure 
or protect the infant from this infection, but we have the further duty of pro- 
tecting nurses, relatives, and physicians. It is hardly necessary to point out 
the extremely infectious character of the discharge from the eyes of a patient 
with gonorrheal ophthalmia or to emphasize the importance of avoiding the 
chance of infecting a clean eye. Every case should be promptly isolated and 
placed under the care of a special nurse. Attendants must be trained in the 
observance of antiseptic precautions, and no detail must be neglected. Cotton, 



AFFECTIONS WHICH ORIGINATE INTRA PARTUM. 



901 






gauze pads, and dressings should be burned after use, and the minutest care 
should be exercised to keep members of the family, especially children, away 
from the patient or anything which has been used about him. The patient 
himself must also be prevented from rubbing his eyes. If a clean eye 
should accidentally be brought in contact with infection, a few drops of the 2 
per cent, silver-nitrate solution should be instilled, after the eye has been flushed 
with boric solution, and then cold applications should be made for two or three 
hours. After this a boric-acid wash should be used occasionally. The duration 
of this form of conjunctivitis may be several weeks, and treatment must be 
kept up according to the symptoms as long as they exist. If corneal infection 
occurs, it is a good plan whenever possible to get the assistance of an ophthal- 
mologist, since there are 
often many details which 
can best be handled by the 
specialist. ^CHZI.^ .-— 

(2) Curative. — To cure a 
patient, the sooner the dis- 
ease is attacked, the better 
is the chance of prompt suc- 
cess. For at least a century 
silver nitrate in solutions of 
varying strength has been 
the mainstay in the treat- 
ment of all forms of conjunc- 
tivitis, and in 1882 Crede 
proposed its use as a pro- 
phylactic in infants. When 
the disease is already pres- 
ent, active treatment must 
be at once instituted, and 
what we must depend upon 
chiefly is antisepsis and local 
cold. The lids and the con- 
junctival sac must be kept 
free from accumulated pus 
and some kind of antiseptic 
must be applied to their sur- 
faces. Often cold must be 
applied continuously if we 

are to expect success. During the first three or four days before the discharge 
becomes purulent, cold compresses must be applied continuously for an hour 
twice or three times a day and free washing of the conjunctival sac should be 
done in addition four or five times a day with a warm, saturated boric-acid solu- 
tion or a 1 : 2000 potassium permanganate or a 1 : 10,000 sublimate solution. 
This is of the greatest importance, and the washings should be frequent enough 
to keep the eyes clear of pus. An eye-dropper, glass syringe, or medicine- 
dropper attached to a fountain syringe can conveniently be used (Fig. 1040). 
The child on its side should be held on a piece of rubber on a nurse's lap and 
the lower eye irrigated, the solution being instilled into the inner angle of the 
eye, enough force being used entirely to wash away the discharge and cleanse 
the conjunctival surface. In addition to this, it is a good plan to instil 
once a day a few drops of a 10 per cent, protargol solution (Fig. 636). It is 







Fig. 1040. — Method of Irrigating the Eye of the 
Infant in Cases of Ophthalmia Neonatorum. 



902 THE PATHOLOGY OF THE NEWLY BORN. 

not necessary to use silver nitrate at this stage, and mercury bichloride will be 
found too irritating in solutions of sufficient strength to exercise active antiseptic 
properties. If the case under observation should turn out to be simply an 
aggravated instance of catarrhal ophthalmia, this treatment will be found 
sufficient; but if pus begins to form and all the symptoms increase, and also 
if the gonococcus can be demonstrated, we must change our treatment to some 
extent. The conjunctival sac must be cleansed much more frequently, at least 
every hour during the day, but perhaps not so often at night, and the lids 
must be kept from sticking together by the method already described. The 
protargol solution must be increased in strength to 20 per cent, and it may 
be used more frequently, preferably after the discharge has been thoroughly 
washed away and the shreds of muco-pus carefully brushed from the conjunctiva 
with bits of cotton or gauze. If the action of the protargol does not seem 
to be favorable, it will occasionally be found advisable to employ a 2 per cent, 
or even stronger silver-nitrate solution, but it is better under such circumstances 
to make the application only to the everted lids and to wash the residue away 
at once with salt solution. The extent of the use of cold applications depends 
somewhat upon the intensity of the inflammation, but in all cases ranging from 
severe to bad, this must practically be continuous. This involves unremitting 
care on the part of the nurse, who will require rather frequent relief. The best 
method to pursue is to have a block of ice in the room and to prepare a number 
of soft gauze pads about an inch or an inch and a half in diameter, which can be 
placed on the ice and thus allowed to become moist and cold. These can be used 
as often as necessary and must be changed as soon as they become warmed. 
Not infrequently it is necessary to place a fresh pad on each eye every minute, 
at the same time that the antiseptic treatment is being kept up. In cases of 
corneal involvement atropin must be used to dilate the pupil, and in all bad 
cases its use is a wise precaution. If there seems to be danger of strangulation 
of the corneal vessels on account of the density of the exudate and consequent 
interference with the nutrition of the cornea, hot applications may be sub- 
stituted for cold for a time so as to stimulate the circulation and absorption. 
It is also occasionally necessary to make radial incisions in the swollen con- 
junctiva in order to relieve the external tension. It is better not to use the 
stronger solutions of silver nitrate and protargol more than once a day. In 
the case of weak infants care must be taken not to disturb the child any oftener 
than is absolutely necessary, for a certain amount of undisturbed rest is essential 
and must be allowed, even if we are not able to cleanse the lids quite as often 
as we should otherwise wish. The child must be kept warm and carefully and 
regularly fed, and any gastro-intestinal disturbance must receive prompt atten- 
tion. In a few very severe cases the swelling and chemosis may be so great 
that a short incision may have to be made in order to relieve tension and give 
access to the conjunctival sac. When such measures are thought necessary, no 
hesitation need be felt in calling upon the expert ophthalmologist for assistance. 
Sometimes a certain amount of chronic inflammation remains after the acute 
symptoms have subsided. This may be treated by the daily applications of 
a 1 per cent, protargol or a 0.5 per cent, zinc sulphate solution. 

Expert Advice. — In view of the danger of loss of sight from this disease 
and the responsibility involved, it is always well for the obstetrician or general 
practitioner to secure the services of an expert ophthalmologist, if possible, in 
every case of the purulent disease. 

2. Gonorrheal Stomatitis. — A gonorrheal infection in infants has its origin 
in the genital tract of the mother, and for that reason it is confined almost 



DISEASES INCIDENT TO CHANGE OF ENVIRONMENT. 903 

entirely to the newly born. Etiology: The delicate mucous membrane of the 
newly born child offers little resistance to this infection, especially after im- 
proper efforts have been made to cleanse the mouth, and any abrasion offers 
a favorable entrance for the gonococcus. A pre-existing or concomitant oph- 
thalmia explains the origin of many cases. Pathology: The hyperemia of the 
acute stage of inflammation is followed by the formation of creamy patches 
upon the hard palate or tongue. But the process is distinctly local and shows 
no tendency to affect the entire stomal mucous membrane. There is a possi- 
bility, however, of an added infection due to staphylococci or streptococci result- 
ing in pathological conditions more serious in character. Symptoms and diag- 
nosis: With stomatitis of this character alone, constitutional symptoms are 
usually absent, and the general health is not particularly affected. Microscopic 
examination of the exudate reveals the nature of the exciting cause. Treatment: 
A saturated solution of boric acid frequently applied is a most efficient agent. 
In more severe cases a mixture of boric-acid solution and hydrogen peroxide 
is very useful. The solid stick of silver nitrate may also be of service. 



IV. DISEASES INCIDENT TO CHANGE OF ENVIRONMENT. 

I. Primary Asphyxia of the Newly Born. 2. Atelectasis Neonatorum, j. Failure of Cir- 
culation. 4. (Edema Neonatorum. 5. Failure of Digestion and Assimilation. Inani- 
tion. 6. Inanition Fever. 

The fetus at birth not only changes its surroundings from an aqueous to 
an aerial medium, but begins to use hitherto quiescent organs and to disuse 
others previously active. Naturally a healthy child should encounter little or 
no difficulty in this physiological readjustment; but it is otherwise with the 
premature or undeveloped. Nearly every one of the more important functions 
may be in abeyance as a result of this congenital debility. The lungs may not 
expand, the heart's action may fail, the stomach may be unable to retain the 
ingesta, assimilation may be impossible, etc. Mere functional incapacity may 
be associated with various affections largely peculiar to this period of life, 
and believed to be the expression of incapacity of the fetus to adapt itself 
to the external world. These affections do not appear to date from fetal life, 
nor have they been brought into connection with any form of infection post 
partum. They are not hereditary, and hence they may be regarded as due 
to a "change of life," just as puberty and the climacteric have their own peculiar 
disorders. 

1. Primary Asphyxia of the Newly Born. — This term is applied to the following 
condition: When an infant delivered without dystocia, and with no symptoms 
which point to subaeration ante partum or intra partum (livid or pallid hue, 
anomalies of the circulation, etc.), fails to respire as soon as the cord is cut, 
we have a state entirety distinct from the ordinary type of asphyxia which 
accompanies dystocia. In some instances these infants do breathe for a short 
time, or the failure of respiration may not set in until several days have elapsed. 
This affection is purely an anomaly of readjustment of the infant to its new 
environment and therefore to be met with, as a rule, in weak and premature 
infants. It should be carefully distinguished from conditions due to labor 
itself — for example, pneumonia due to aspiration of amniotic fluid; and also 
from the so-called spurious asphyxia in which the respirations are so shallow 



904 THE PATHOLOGY OF THE NEWLY BORN. 

that they pass unnoticed. It must also be borne in mind that while many 
cases of primary asphyxia of the newly born are due to simple failure of the 
lungs to expand, others are rendered possible by the presence of disease or 
malformation of fetal origin (syphilis of the lungs, hydrothorax, defects of the 
diaphragm, etc.)- The mechanism of these cases is not difficult to understand. 
Neither the lung tissue nor the parietes of the chest are sufficiently developed 
for respiration, and when malformations or diseases are present, the mechanical 
hindrance is also capable of accounting for the failure of respiration. The 
thorax of the premature child may undergo rhythmic movements (this is said 
to occur even in utero) without any corresponding inflation of the lung. For 
all practical purposes the remainder of this subject may be considered under 
" Prematurity " and " Asphyxia Intra Partum." 

2. Atelectasis. — In the healthy infant born under favorable circumstances, 
the function of respiration is established in the first minute of life, a few vigorous 
cries expanding the lungs freely. In other infants, however, the lungs do not 
undergo inflation, or only a portion of the upper lobes is inflated while the 
remainder of the organs does not change from the fetal state. This is termed 
congenital atelectasis. While atelectasis may occur without causing asphyxia, 
and while the latter may not be due necessarily to inability of the lungs to inflate, 
in the majority of cases the two conditions must necessarily coexist. The lungs 
of a healthy infant expand as soon as the cord is cut, but in the weak or pre- 
mature a certain portion refuses to become aerated. The child may be threat- 
ened with death by asphyxia, and the application of the usual management 
for that condition may reanimate it. The atelectatic area, however, may still 
persist in the affected locality and threaten the child's life during the ensuing 
hours or days. If the newly born has not succeeded in breathing at all and has 
succumbed at once to asphyxia, the atelectasis is of course absolute. But if, as 
often happens, respiration has been inaugurated either spontaneously or as a 
result of treatment, some of the lung tissue — as a rule, both upper lobes — is 
not only inflated but emphysematous, the rest remaining in the fetal state. 
If the survival of the child continues, air begins to enter the posterior aspect of 
the lower lobes. The central portion of the lungs is the last to yield. Despite 
the apparent solidity of the atelectatic tissue, it may readily be inflated artifi- 
cially even months after birth. When these children do not succumb at birth 
they simply present the picture of debility or prematurity and are menaced by 
death in various forms (marasmus, convulsions, etc.). If they are doomed to 
perish of asphyxia, cyanosis gradually develops. The prognosis, however, is 
not hopeless, as many of these children survive. 

Etiology. — Abnormal conformations in the respiratory tract are rare, so that 
practically it may be said that the condition is due primarily to feeble respiration 
following some injury to the centers in the brain from prolonged labor or in- 
strumental delivery. Atelectasis may occur, however, in infants whose respira- 
tions are apparently normal in rhythm but not sufficiently full and forcible to 
cause complete pulmonary expansion. 

Pathology. — The conditions found at autopsy depend upon whether the 
child lived a few days or longer. In the newly born both lungs are generally 
involved. The anterior borders of the upper lobes are inflated and light pink 
in color and emphysematous from the added strain thrown upon them; while 
the rest of the lung is in the fetal state, dark brownish in color, not inflated, and 
firm to the touch. In older infants the posterior parts of the lower lobes are 
found not inflated or only superficially so, the central portion of the lobes being 
of no service in the act of respiration. Incidentallv there mav be found various 



DISEASES INCIDENT TO CHANGE OF ENVIRONMENT. 905 

degrees of congestion of the liver, spleen, stomach, and intestines, due directly 
to the imperfect pulmonary circulation. 

Symptoms. — In infants with a history of asphyxia at birth atelectasis is most 
noticeable. They gain little in weight, the circulation is poor, the extremities are 
cold, they cry feebly if at all, and do not take nourishment well. In some cases 
death occurs in a few days, while others live for weeks and months. Cyanosis 
may develop at any time and death follow from asphyxia or convulsions. Many 
infants, however, who begin life most unpromisingly gain steadily under favor- 
able conditions and recover completely. 

Diagnosis. — The general condition of the infant gives far more information 
than does physical examination of the chest. Owing to the fact that both lungs 
are generally involved, the ordinary advantage of comparing the two sides 
of the chest is lost ; but if it happens that one lung only is the seat of the 
trouble, we may find the respiratory murmur feebler over that portion of 
the chest. Cyanosis or convulsions in the very young should always suggest 
the possibility of an existing atelectasis. 

Treatment. — If a vigorous cry does not occur spontaneously at birth, the 
use of the hot and cold bath should be resorted to. Spanking is often effec- 
tive and should be repeated at regular intervals if necessary. In those pre- 
maturely born careful attention should be directed to regulating the body 
temperature by the use of cotton, hot baths, or an incubator. Friction and 
gentle massage are of value in some cases. If convulsions or asphyxia develop, 
the hot bath offers the greatest hope of benefit. 

3. Failure of Circulation. — The various malformations of the heart are some- 
times of such degree that death results in the neonatal period. In the milder 
varieties the duration of survival maybe indefinite. These anomalies give rise 
to cyanosis. Some debilitated infants appear to succumb to simple arrest of the 
circulation. The condition known as oedema neonatorum is probably associated 
with a feeble right heart, with overfilling of the venous circulation. 

4. (Edema Neonatorum. — The oedema appears in various superficial localities 
and in some cases general anasarca may develop; the serous cavities, however, 
are rarely involved. Unless the infant dies as a result of disability, the oedema 
may disappear within a few days. Relapses are frequent. In sclerema neo- 
natorum failure of the circulation is one of the most striking symptoms, although 
it cannot be set down as the cause of the affection. 

5. Failure of Digestion and Assimilation. — Marasmus as ordinarily described 
is a condition which develops after the neonatal period and extends over a con- 
siderable period of time (see page 924). An analogous condition of the newly 
born, which, however, leads much more rapidly to death, is generally known as 
inanition. A peculiar phenomenon connected with starvation in the newly 
born is a rise of temperature (hyperpyrexia neonatorum). According to Holt, 
however, the trouble in these cases may lie entirely with the mother, whose 
breasts are dry. Children who are born healthy, if they obtain no milk by the 
third or fourth day of life, show the commencement of inanition by a rise 
of temperature to 101 F. or upward, which subsides as soon as the child 
is fed. Inanition which is the fault of the child may be due to refusal of 
the breast or of food, or to absolute inability to nurse or to retain the milk, or, 
finally, to inability to digest and assimilate it. These causes are all operative 
in weak and premature infants at birth. Naturally the various phenomena of 
prematurity or debility coexist, so that it is difficult to assign particular symp- 
toms to inanition. The exhaustion and debility are accentuated and the child's 
life is rapidly forfeited, sometimes in two or three days. In cases in which 



906 THE PATHOLOGY OF THE NEWLY BORN. 

some nourishment is taken gain in weight is a good sign, and vomiting is a bad 
one. The management of these cases is necessarily included under that of " pre- 
maturity " and "congenital debility." Refusal of food is met by gavage. If 
vomiting is present, the milk thus given should be diluted or an attempt should 
be made to find something which the stomach will tolerate. (Compare Infan- 
tile Cachexia, page 924.) 

6. Inanition Fever. — It was formerly supposed that inanition fever did not 
occur as a distinct condition, but observations during the past ten years prove 
it to be comparatively frequent, especially from the second to the fifth day. 
It is really due to starvation, the infant being unable to obtain the proper 
amount of nourishment from the breast as a result of limited or negative supply 
of milk, of depressed nipples, or of inflammatory conditions. It is not confined 
to premature or delicate infants, but occurs quite as frequently in those ordi- 
narily vigorous. Fever is the most important symptom; it ranges from 102 to 
105 F., and generally reaches its highest point on the third or fourth day of life. 
The infants lose weight rapidly, not infrequently eight ounces in twenty-four 
hours, and the condition is one that quickly causes alarm. Various other symp- 
toms accompany the fever and loss of weight. A certain number of cases are fret- 
ful and restless, while others show hot, dry skin, extreme irritability, and much 
prostration. When all other causes of fever can be excluded, and investigation 
proves that the proper amount of nourishment has not been taken by the infant, 
the case may be called ' ' inanition fever. ' ' Treatment consists in the administra- 
tion of water at regular intervals until thirst is alleviated and the temperature 
falls. If necessary, a wet-nurse should be secured or artificial feeding begun. 



V. DISEASES DUE TO BACTERIA AND FUNGI. 

I. Umbilical Sepsis. 2. Septic Coryza. 3. Septic Pneumonia. 4. G astro-intestinal Sepsis.. 
(1) Ulcerative Stomatitis. (2) Gangrenous Stomatitis, (3) Parotitis. (4) Retro- 
pharyngeal Abscess. (5) G astro-enteritis. 5. Cutaneous Sepsis. (1) Dermatitis ex- 
foliativa neonatorum (Ritter's Disease). (2) Pemphigus acutus neonatorum. Septic 
Pemphigus. (3) Impetigo contagiosa neonatorum (Periumbilical Pemphigus). (4) 
Ecthyma neonatorum. (5) Multiple Abscess. (6) Erysipelas. 6. Tetanus. J. Aphthce. 
8. Thrush. 

The newly born infant may be attacked by the omnipresent pathogenic bac- 
teria, which may cause infection at the navel, in the mouth, or the gastro-enteric 
tract, etc. ; also by fungi. The principal members of this group are sepsis in its 
manifold aspects, trismus, aphthae, etc. The bacteria which are pathogenic to the 
newly born include the ordinary exciters of suppuration (streptococci and staph- 
ylococci), the germs of tetanus and erysipelas, and to a certain extent any virulent 
micro-organism which may cause chance infection. The newly born enjoys a 
relative immunity from many infectious diseases, and, generally speaking, only 
those bacteria need be discussed which show a particular tendency to attack 
the infant as it emerges into the world. The gonococcus, since it menaces the 
unborn child, is placed among the causes of intra-partum diseases. Of fungi 
which tend especially to attack the newly born, it will be sufficient to mention 
those which cause aphthous stomatitis and thrush. 

Septic Infection. — General Remarks. — By septic infection in the newly born 
must be understood a systemic disease which takes the form of an extremely 
severe infectious process, begins usually at the navel, and later involves in a 



DISEASES. DUE TO BACTERIA AND FUNGI. 907 

greater or less degree other parts of the body. It is one of the most dreaded 
affections of early life. 

Frequency. — When proper aseptic and antiseptic precautions enter into the 
details of delivery and care of the newly born, few cases of septic infection follow. 
The great majority of cases are referred to influences which seem to be present 
and to flourish at intervals in lying-in hospitals or wherever puerperal infection 
finds a harbor. It naturally is more common in those localities and among 
those people who do not enjoy the blessings of modern obstetrical attendance, 
though it has also its victims among the best classes of society. 

Pathology. — In eight cases out of ten the process begins in the umbilical 
vessels or in the connective tissue about the navel ; the blood-clots in the vessels 
and the clean-cut edges of the stump offering good soil for bacterial development. 
Injuries or abrasions of the skin and mucous membranes and of the conjunctiva 
offer other avenues of entrance. The precise manner of communication in these 
cases is obscure, but careful search will reveal in the majority of cases the place 
of infection, because the bacteria which are the real cause of the disease must 
have penetrated into the body from the external world. When it is once in the 
system, it can be disseminated through various channels. It may be carried 
by the lymphatics into the general circulation or a purulent phlebitis may be 
excited at the point of infection, and this in turn may excite by embolism 
analogous lesions in other parts of the body. The most striking feature at 
autopsy is that there is never a lesion of one organ exclusively. Several or, 
it may be, almost all the organs and systems exhibit foci of disease. 

Symptoms. — These usually begin in the first week, never later than the 
twelfth day — and are those of a general septic poisoning with the local manifes- 
tations at the point of entrance. The fever is characteristically irregular. It 
may look like typhoid fever or. so closely resemble quotidian or even tertian 
intermittent fever as to lead to a wrong diagnosis. Other cases show little or 
no elevation of temperature. Cutaneous symptoms, icterus, and either puncti- 
form petechias or extensive hemorrhages are common. The pulse is generally 
rapid and of poor quality and the respiration is disturbed. Emaciation always 
occurs. The nervous symptoms are restlessness, irritability, and muscular 
twitchings, with stupor or convulsions in the later stages. The abdomen is 
generally swollen and tender, and we are able at times, by pressing along the 
abdominal walls toward the umbilicus, to squeeze out a few drops of purulent 
material. The spleen may be enlarged and palpable. There are sometimes 
severe intestinal symptoms, a septic diarrhea with greenish or dark or bloody 
stools of a very foul odor. The inflammatory processes in the brain, lungs, 
and heart often fail to give well-defined symptoms. 

Diagnosis. — The diagnosis of septic infection is not difficult in well-marked 
cases, particularly if the mother develops puerperal septicemia. It is more 
difficult in isolated cases in which no entrance for bacteria can be discovered, 
when the symptoms are ill defined, and when the child comes under observation 
late with an imperfect history. Inflammation of the nose, eye, or joints should 
suggest the possibilities of the case, the importance of not regarding any single 
local process as the whole cause of the illness being borne in mind. 

Prognosis. — This should be guarded even in the milder forms. The severe 
cases are generally fatal, owing to the feeble resistant power of the infant. 

Treatment. — In the entire subject of septic infection nothing is so important 
as the means employed for its prevention. Antisepsis in its relation to delivery 
and the care of the infant is capable of preventing the disease. It is the duty 
of the physician to carry out the strictest antiseptic details in every case of labor. 



908 THE PATHOLOGY OF THE NEWLY BORN. 

The utmost aseptic care must be observed in ligating the cord and in dressing 
it. When infection occurs, the infant should be isolated at once. Since there 
is no specific for septic infection the remedial treatment can only be sympto- 
matic. The inflammatory processes within the body cannot be attacked 
directly, and medicinal methods are resolved into proper feeding and necessary 
stimulation. External suppurative processes require surgical procedure. 

i. Umbilical Sepsis. — This variety represents the type of sepsis neonatorum, 
and perhaps four-fifths of the clinical material. The cord may be infected 
either at the time of ligation or afterward during the sloughing and healing 
periods. Contaminated ligature material and dressings are chiefly responsible 
for infection, but after the stump of the cord has fallen the often immature 
scar is still exposed to the action of pathogenic germs. Before sloughing, the 
arteries, veins, and lymphatics are all capable of absorption, but afterward 
the vein alone, which often retains some of its lumen for a considerable period, 
is held to be responsible for infection. The subject of umbilical sepsis is one 
of extreme perplexity. The local lesions exhibit the greatest divergence of 
type. While in one series of cases arteritis predominates, a second reporter 
finds hardly any lesion but phlebitis, and a third finds more lymphangitis than 
either of the other lesions. The same absence of law is seen in the consecutive 
lesions. In some cases the local lesions, of whatever nature and severity, 
remain localized throughout. In other cases generalization occurs, sometimes 
rapid and fatal, at other times more deliberate and less malignant. The follow- 
ing classification of umbilical sepsis is now recognized at the Tarnier Clinique 
(Paris): (i) Infection of the cord proper. This occurs only in putrefaction of 
the stump. (2) Infection of the granulation tissue of the wound after detach- 
ment of the stump. This occurs when for some reason the cicatrization is not 
complete. A minute wound is left which suppurates and sometimes produces 
excessive granulations. The discharge may be considerable, and is then known 
as blennorrhea of the umbilicus; when the granulations attain a large size, they 
are known as umbilical fungus. (3) Infection of the periumbilical tissues (skin, 
subcutaneous tissue, lymphatics, etc.). This is manifested by erysipelas or 
lymphangitis, with or without abscess formation. In rare cases gangrene 
occurs, with the formation of the so-called umbilical ulcer of former days. 
Another type of local infection is periumbilical pemphigus. (See Sepsis of the 
Skin.) Phlegmon of the periumbilical region is announced by the formation 
of an indurated mass about the cord. Suppuration does not occur invariably, 
although abscess-formation and sloughing form the usual termination. All the 
preceding forms of sepsis are purely local; and in order that general infection 
should occur, it is necessary for the vessels of the cord to be involved. Hence 
the final type: (4) Infection of the umbilical vessels. This is able to occur with 
or without local mischief. The microorganisms may enter the circulation imme- 
diately and set up fatal sepsis. It is possible that a very slight, transitory 
local reaction always occurs, but it is frequently impossible to demonstrate its 
existence. 

Treatment. — Local sepsis is managed on ordinary surgical antiseptic princi- 
ples. Exuberant granulations should be touched with tincture of iodine or 
nitrate of silver. Accumulations of pus should be evacuated and pyogenic 
surfaces irrigated. For an ordinary dressing an antiseptic powder (boric acid) 
may be used. In the more severe types ichthyol, 50 per cent., is recommended. 

2. Septic Coryza. — The coryza of the newly born is not necessarily due to 
exposure. According to Bar, it is frequently encountered in children who have 
been exposed to the contact of septic amniotic fluid. Despite its infectious 






DISEASES DUE TO BACTERIA AND FUNGI. 909 

character, it is essentially a benign and self-limited affection, and only excep- 
tionally does the inflammatory process invade the sinuses and middle ear. It 
has recently been claimed that many children are born with adenoids, and 
that this condition is manifested by a coryza neonatorum. The treatment is 
carried out along the same lines as that in older individuals. At the Tarnier 
Clinique mentholized oil is applied by a post-nasal tube of special pattern. 

3. Septic Pneumonia. — The subject of pneumonia during the first few days 
of life is one of great obscurity, and doubtless comprises several quite distinct 
conditions: (1) In aspiration-pneumonia, which is a simple catarrhal process, it 
is conceivable that the amniotic fluid aspirated intra partum might be septic 
and thereby directly infect the bronchi with streptococci, etc. When Bar states 
that infectious pneumonia is often seen after a child has breathed in ittero, 
he alludes to a condition which is by no means necessarily septic. (See Aspira- 
tion-pneumonia.) The course of this affection as described by Bar is that of 
this simple irritant type. (2) Since bronchial pneumonia is a deadly foe of 
infancy in general, it is more than likely that many cases in the newly born 
are derived in the ordinary way, from epidemic influence, and do not represent 
a type of neonatal disease. (3) Holt and other pediatrists describe a well- 
marked form of septic purulent pleuropneumonia which is not recognizable 
during life. Since it often accompanies sepsis in other localities, it doubtless 
represents a phenomenon of general infection, and corresponds to the purulent 
pleurisy of the newly born described by Bar. 

4. Gastro-intestinal Sepsis. — Some of these infections may date from the 
ante partum or intra partum period, as when the fetus swallows septic amniotic 
fluid. The cause most in evidence after delivery would be nursing an infected 
nipple or contact of the mouth with some unclean object. Some of the expres- 
sions of this sepsis of buccal origin are as follows: 

(1) Ulcerous Stomatitis. — This condition is usually due to the strepto- 
coccus, and has received numerous designations. It appears in the form of 
multiple plaques of a grayish hue representing a diphtheroid false membrane, 
which when removed discloses ulcerated surfaces with sharply cut borders. 
Their number and site are often characteristic, there being two plaques seated 
symmetrically on the pterygoid border of the vault of the palate. In some 
cases they are seated about the frenula of the lips. The course pursued is usually 
benign, but erysipelas has sometimes been traced to the lesions. 

(2) Gangrenous Stomatitis (Cancrum Oris, Noma). — This disease is 
rare. It occurs also in other situations besides the mouth, such as the female geni- 
tals, the nose, and the ear. It generally complicates some exhausting disease, 
such as measles, the child being always in a weakened condition. Symptoms : The 
gangrene spreads rapidly, there is extreme prostration, the temperature is 
elevated, the pulse weak, the breath foul. Sloughing generally takes place on 
one side of the face, though occasionally on both. Pain is sometimes absent, 
and only rarely is it severe. As a rule, there are no alarming hemorrhages. 
The ordinary duration of this disease is a few days. The prognosis is bad. 
Treatment: Prophylaxis is most important. The mouth should be persistently 
and carefully cleaned in every acute infectious disease. When the disease is 
once recognized, the affected parts should be excised and cauterized. The 
actual' or Paquelin cautery is to be preferred, although nitric acid may be used. 
Hydrogen peroxid should be employed for cleansing the buccal cavity. In the 
mean time a supporting and stimulating general treatment should be followed 
up. Every case must be isolated in order to avoid the spread of the disease. 

(3) Parotitis. — Both the parotid and the submaxillary glands have been in- 



910 THE PATHOLOGY OF THE NEWLY BORN. 

fected apparently by the migration of pyogenic germs from the mouth along 
the excretory ducts. At first pus discharges by the latter structures, but in 
time these become clogged and incisions are necessitated. 

(4) Retropharyngeal Abscess. — This affection, which, according to Bar, 
is often overlooked, occurs as a variety of buccal sepsis. On account of the 
resulting dysphagia the infant will perish unless relieved. There is also a 
marked constitutional reaction in these cases. 

(5) Gastro-enteritis. — Of recent years severe streptococcus gastro- 
enteritis, followed perhaps by general sepsis, has been traced to nursing by 
the newly born from an infected breast. If the condition cannot be explained 
in this manner it may have been due possibly to intra-partum infection. The 
disease begins with vomiting and diarrhea, the ejected matter having a foul 
odor. If the infection is of a mild local type, the symptoms disappear within 
a few days. Otherwise we see persistent diarrhea develop, with inanition and 
evidences of systemic infection. If the infant continues to absorb pus from the 
infected breast, the chances of a severe type of infection are increased. 

5. Cutaneous Sepsis. — (1) Dermatitis Exfoliativa Neonatorum (Ritter's 
Disease). — Definition: An exfoliative process in the skin of the newly born 
which is believed to bear the same relation to pemphigus neonatorum that 
exfoliative pemphigus bears to common pemphigus in adult life. Etiology: Rit- 
ter's disease is believed to be due entirely to septic infection of the child from 
the maternal passages (from midwives, etc.). The ordinary exciters of suppura- 
tion may be cultivated from the skin. Quasi-epidemics have occurred. Symp- 
toms: The affection usually begins about the mouth and extends over the entire 
surface. The skin becomes intensely red and desquamates in large, loose flakes, 
which tend to adhere to the bedding, etc. The temperature is subnormal. 
Diagnosis: There is no affection of the newly born which simulates Ritter's 
disease. Prognosis: About one-half the children recover. Relapses occur. 
Treatment: The continuous bath is indicated at first. If impracticable, alkaline 
lotions should be applied until desquamation ceases, and followed with ichthyol 
ointment. 

(2) Pemphigus Acutus Neonatorum (Septic Pemphigus). — Definition: A 
bullous exanthem not necessarily the same as pemphigus in the adult. It 
corresponds to some extent with the bullous type of impetigo contagiosa. 
Etiology : Pemphigus of the newly born appears to be due to the ordinary 
exciters of suppuration, which may be cultivated from the fluid contents of 
the bullae. The source of the disease may be the maternal passages, or other 
infants who have the same affection, etc. Symptoms: Within the first few days 
of extrauterine life bullae make their appearance upon some portion of the 
integument and tend to involve the entire surface. The contents may be 
serous, purulent, or bloody. Numerous evidences of general sepsis may become 
apparent. Diagnosis: While a few other diseases of the newly born may present 
bullae (syphilis, erysipelas), none should be confounded with pemphigus. Prog- 
nosis: This is unfavorable and worse in proportion to the amount of suppuration, 
hemorrhage, and constitutional disturbance. Treatment: The blebs should be 
evacuated, the surface cleansed, and ichthyol ointment (50 per cent.) applied. 
Measures must be directed against the constitutional infection. 

(3) Impetigo Contagiosa Neonatorum (Periumbilical Pemphigus). — 
For a description of impetigo contagiosa as it occurs in older children the reader 
is referred to works on dermatology. While the newly born infant might 
exhibit the ordinary lesions of this disease if exposed in an epidemic, there is 
one individual phase which it alone exhibits: viz., the so-called periumbilical 



DISEASES DUE TO BACTERIA AND FUNGI. 911 

pemphigus, — in reality a localized bullous form of impetigo contagiosa which 
begins about the navel during the first few days of life. Staphylococci have 
been cultivated from the contents of the blebs. This form of impetigo is prob- 
ably due to a mild local infection, and in fact appears to differ only in degree 
from ordinary pemphigus neonatorum, which sometimes appears to start from 
the navel. Periumbilical pemphigus should be treated like the more generalized 
form of the disease. 

(4) Ecthyma Neonatorum. — Definition: Like the preceding affections, 
ecthyma is a manifestation of sepsis of the newly born in which cutaneous 
lesions predominate. In the future all these affections will doubtless be 
regarded as types of one fundamental infection which may announce itself 
by various lesions, bullae predominating in one case and pustules in another. 
It is at present impossible to state positively whether these eruptions originate 
in the skin or are preceded by a blood infection. Ecthymatous lesions of the 
newly born resemble those in the adult, and consist of large subepidermic 
pustules having a broad indurated base. At this period of life there is a special 
tendency for the pustule to ulcerate. In certain cases there is a marked inclina- 
tion toward ulceration in depth (ecthyma terebrante). Etiology: The ordinary 
exciters of suppuration are usually at fault (staphylococci and streptococci) ; in 
particular instances some other germ, such as Bacillus pyocyaneus, may be 
responsible for the lesions. According to the obstetricians of the Paris clinics, 
this ecthyma occurs by preference in premature and congenitally feeble children, 
in the cachectic, etc. Symptoms: The lesions occur most frequently on the 
head, neck, and abdomen. When the process is at its height, they appear 
chiefly as ulcers with rounded borders surrounded by areas of a purple hue. The 
development of the pustules is preceded or accompanied by fever, vomiting, 
diarrhea, etc. A special localized form of this suppuration is sometimes seen 
about the nails of the newly born — the so-called "run round." Diagnosis: The 
recognition of the pustulo-ulcerous lesions of ecthyma is not difficult, and the 
real diagnostic difficulty lies in arriving at a knowledge of the predisposing 
cause; for clinically ecthyma, while technically a contagious disease, is rather 
the expression of an underlying cachectic state. Treatment: Measures must be 
directed to the general welfare. If the patient presents crusted lesions, the 
scabs must be removed by sweet oil, etc. The exposed surface and ulcers in 
general should be treated with mild solutions of nitrate of silver. 

(5) Multiple Abscesses. — Multiple abscesses in the newly born consist of 
collections of pus of varying size and depth beneath the skin. Two types occur: 
viz., the superficial or benign and the deep or septic. Etiology: The superficial 
or benign type of abscess appears to represent a local infection with the sta- 
phylococcus or streptococcus, which germs are often derived originally from 
some maternal lesion such as purulent mastitis. The deeper sort may form in the 
subcutaneous tissue or between contiguous muscles. In these cases the infec- 
tious pus appears to have been swallowed by the infant while nursing from an 
infected breast. Abscesses coexist in the large viscera, and the condition is 
really one of profound pyemia. Symptoms: These abscesses cause swellings which 
may be as small as a pea or as large as a small hen's egg. In the benign form the 
abscesses appear in crops, and are usually of small dimensions. The larger, more 
deeply placed abscesses of septic origin behave very much like ordinary cold 
abscesses. Their number and extent make the condition most serious, to say 
nothing of the great likelihood of the involvement of subjacent viscera. 
Bar speaks of opening forty-five of these abscesses in one child. Death finally 
occurred, and on autopsy a collection of pus was found in the posterior mediasti- 



912 THE PATHOLOGY OF THE NEWLY BORN. 

num. Diagnosis: This should readily be made with the exploring needle if 
any doubt arises as to the nature of the affection. Treatment: A newly born 
infant should never nurse from a breast the seat of abscess, or with any lesion 
whatever of the nipple, areola, or breast. If abscesses have formed, they 
should be evacuated, and the larger sort may require drainage. If the earliest 
abscesses are evacuated, irrigated with sublimate, and sealed with collodion, 
the spread of the disease may be partially checked. 

(6) Erysipelas. — Erysipelas in the newly born, as in adults, is an inflam- 
mation of the skin due to a specific germ, Streptococcus erysipelatis. It is 
especially seen in the first two weeks of life, and usually has its origin in the 
navel, the small fissures of the anus, or abrasions of the skin. Pathology: The 
skin and subjacent connective tissue are congested and swollen and infiltrated 
with serum, fibrin, and leucocytes, the process continuing in many cases to 
suppuration, ulceration, and gangrene. Metastases may form in the lungs, 
heart, brain, kidney, and spleen. If the umbilicus is the primary seat, it is 
likely that localized or general peritonitis will follow. Acute degeneration of 
the liver and kidneys is a common step in the progress of the infection. Symp- 
toms: Invasion is usually marked by vomiting, high fever, and severe pros- 
tration. Locally the skin is hot, dry, hyperemic, and tender, and the inflamed 
area rapidly increases in size. Restlessness and vomiting with the fever and 
prostration persist during the course of the disease, which in the newly born 
usually ends disastrously. Especially is the prognosis bad when the umbilicus 
is the starting-point. Treatment: Isolation should be practised at once. Locally 
an ointment of ichthyol, 10 to 20 per cent, in lanolin, should be applied continu- 
ously over the inflamed parts. If suppuration occurs, wet dressings of lysol, 
creolin, or bichloride may be of advantage. Constitutionally we must support 
the child with alcohol and strychnin in free doses and the regulated use of baths 
and packs. Artificial feeding may be required during the entire illness, par- 
ticularly when there is any danger of infecting the mother's breasts. 

6. Tetanus. — Tetanus is an acute infectious disease of rather infrequent 
occurrence, the main symptom of which is tonic spasm involving the muscles of 
the jaws and neck or the entire muscular system. There is no ground for 
establishing tetanus neonatorum as a distinct form, since its etiology and course 
are analogous at all times and at all ages. The specific cause is a bacillus which 
is rather widespread and in some places very abundant, occurring in the soil 
with other germs. It produces no special local lesion, but affects the body by 
its elaboration of tetano-toxin, a most virulent poison. The germ enters the 
body through abrasions and fresh-cut surfaces, more often through the umbilicus. 
Pathology: No characteristic lesions have been found in the spinal cord or brain. 
Symptoms: These may develop within a few days after inoculation or they may 
be deferred for one or two weeks. Ordinarily the first thing noticed is the in- 
fant's inability to nurse, due to rigidity of the muscles of the face and jaws and 
nape of the neck. This rigidity spreads by degrees to the muscles of the trunk 
and extremities. In many cases the continuous tonic spasm is occasionally 
interrupted by sudden and irregular paroxysms, during which all the affected 
muscles become still more tense and opisthotonos is pronounced. The jaws 
are firmly pressed together and can be opened but slightly. The face has a 
peculiar drawn painful expression, the respirations are embarrassed, the pulse 
is rapid and weak, and prostration is pronounced. Fever is generally present, 
often rising to 105 F. before death. Recovery sometimes occurs in the milder 
forms, but when the disease is once established the prognosis is bad. Treat- 
ment: Avoid infection by observing perfect aseptic precautions in the dressing 
of the cord and the treatment of denuded surfaces. When systemic poisoning 



DISEASES DUE TO BACTERIA AND FUNGI. 913 

is evident, the point of entrance should be attacked and made as clean as possible. 
Antitoxin should be administered by the hypodermic method. Further than 
this we must rely upon the symptomatic remedies with the aim of preserving life. 
Remedies which lessen the irritability of the nervous centers, such as potassium 
bromide, gr. 4 to 8, every two hours; or chloral hydrate, gr. 2 to 4, every one or 
two hours per rectum, have a certain amount of value. Calabar bean has been 
much used in doses of gr. ^ to J several times daily by the hypodermic method. 
All unnecessary handling should be avoided and everything done to prevent dis- 
turbing the infant. Feeding by the nasal tube is necessary when the jaws can- 
not be forced apart, and stimulants may be given by the same channel. 



DISEASES DUE TO FUNGI. 

Although there is no positive proof that these conditions are due to fungi, 
still they are most conveniently classed here. 

7. Aphthae. — Aphthae, sometimes called vesicular or follicular stomatitis, is a 
morbid condition of the mouth characterized in the early stages by the appear- 
ance of whitish vesicles followed by superficial ulcers, mostly on the inside 
of the lips and the edges of the tongue. It appears at any time in infancy, but 
infrequently in the newly born. Etiology: Authorities tend to the belief that 
it is nervous in origin. So far there is no testimony to prove its bacterial origin. 
Probably in some instances the exciting cause is some derangement of the 
digestive organs which is not appreciable. Pathology: A number of small, 
round, whitish vesicles first appear under the epithelium, with some congestion 
of the surrounding mucous membrane. In two or three days the epithelium 
falls off and ulcers are formed, always superficial. Ordinarily they heal in from 
seven to ten days. Symptoms : Several crops of ulcers may follow in succession 
and seriously interfere with the nutrition of the child. Treatment: Prophylaxis 
consists in scrupulous cleanliness of the mouth, especially at the time of nursing. 
Cold water should be given freely. The mouth should be kept properly cleansed 
with solutions of boric acid or Dobell's solution. Powdered alum dusted on or 
the judicious use of solid alum or the solid stick of silver nitrate generally hastens 
the process of healing. 

8. Thrush. — The term thrush signifies a form of inflammation of the buccal 
mucous membrane, the peculiar feature of which is the formation of curd-like 
points or patches on the parts involved. It occurs any time in the first few 
months of life. Etiology: It has been definitely settled that Oidium albicans is 
not the cause, but another variety of fungus, parasitic in character, the nature 
of which has not yet been fully determined. It is more often seen in infants 
who suffer from inattention and uncleanliness and in those who are constitu- 
tionally enfeebled. Pathology: The spores attach themselves to the cells lining 
the cheeks and on the surface of the tongue and a simple inflammatory process 
results. This is followed by the appearance of minute white spots or granules, 
some of which remain distinct while others coalesce to form patches of greater 
or less extent. It is not at any stage a purulent inflammation, unless complicated 
by other elements of infection. Diagnosis: When the patches are forcibly sepa- 
rated from the parts beneath, small bleeding points mark the previous sites of the 
growth of the fungus, while the milk curds which they so closely resemble are 
easily wiped off. Treatment: Prophylaxis is most important; careful attention 
to cleanliness will prevent the majority of cases. Nipples, bottles, etc., should 
be scrupulously clean. To cure the disease a saturated solution of boric acid or 
a solution of sodium bicarbonate applied on a swab is usually all that is required. 

58 



914 THE PATHOLOGY OF THE NEWLY BORN. 

VI. DISEASES OF UNKNOWN NATURE. 

I. Omphalorrhagia. 2. Melena. j. Miscellaneous Hemorrhages. 4. From Genitals in 
Female Infants. 5. Sclerema Neonatorum. 6. Buhl's Disease. 7 . WinckeVs Disease. 
8. Mastitis, g. Jaundice. 

The preceding causes named under Sections I to V, and often the cooperation 
of two or more of them in a single case, are responsible for the large mortality 
among the newly born. The vital statistics of New York show that in about 6 
per cent, of all births the children die within the first four weeks. If to this 
number we add the still-births, we find that in 14 per cent, of all births the 
children are unable to survive. Eross made an extensive collective investiga- 
tion in 1893 and found that 10 per cent, of all children die within the first month. 
This author assigned "congenital debility" as the cause of death in these cases 
in over 50 per cent, of the material. If more of these cases came to autopsy 
the matter would assume a different complexion. Thus, Brothers * made 47 
post-mortems on children who were either still-born or who died within a fort- 
night after birth, and found in most cases definite organic lesion sufficient to 
have caused death. Disease acquired after birth is extremely rare (Brothers 
records one case of intussusception). Intra-partum affections, on the other 
hand, must be very common, judging from the amount of cerebral hemorrhage 
and catarrhal pneumonia (provided that the latter is due to aspiration of amniotic 
fluid). Enough has been said to illustrate the great complexity of the subject 
of infantile mortality. There can be little doubt that a condition of subdevelop- 
ment, whether due to prematurity or severe maternal disease or both, furnishes 
a very strong predisposition to all the other conditions which menace the newly 
born. If we exclude from consideration that element of birth mortality which 
is due to actual fetal disease and malformation and to infection intra partum 
and post partum, we may recognize as the two leading factors the subdevel- 
opment of the fetus on the one hand, and dystocia on the other. The 
condition of subdevelopment, which is practically synonymous with congenital 
debility, is probably responsible for more than one-half of all infantile mortality, 
and the actual exciting cause of death is of no special significance. The mor- 
tality from dystocia is due principally to asphyxia and cerebral hemorrhage, 
with a certain proportion of deaths from aspiration-pneumonia as a result of the 
entrance of amniotic fluid into the lungs. 

Hemorrhages in General. — Somewhat different in character from the preced- 
ing is the marked tendency of the neonatal blood-vessels to rupture, insomuch 
that a sort of hemorrhagic diathesis appears to exist. Hemorrhages either occur 
independently or complicate other conditions, especially infectious conditions. 
Independent hemorrhages occur principally from the navel (omphalorrhagia), 
intestinal canal (melena), and the subcutaneous tissues. They are of rare occur- 
rence and have no connection with hemophilia, since the disposition to bleed 
ceases with the neonatal period. The true hemorrhagic diathesis is very seldom 
manifested at birth. Traumatic hemorrhages are not considered in this connec- 
tion, although the tendency of the newly born to bleed acts undoubtedly as a 
predisposing cause. Neither are the hemorrhages which characterize syphilis 
in the newly born and septic infection post partum included here. The dis- 
position of the newly born to hemorrhage may be attributed to the new demands 
made upon the circulation by extrauterine life and the extreme fragility of the 
capillaries. The blood itself may undergo some peculiar change, and the fact that 

* "Infantile Mortality," 1896. 






DISEASES OF UNKNOWN NATURE. 915 

actual extensive hemorrhage is not of common occurrence has caused the belief 
in some quarters that the blood is altered by some agency, perhaps a bacterium, 
before it can escape in such large quantities. These hemorrhages are oftener 
fatal than not, but if the child can survive beyond the neonatal period it is- 
usually safe, for then the unknown process of readjustment appears to be com- 
pleted. 

i. Omphalorrhagia. — This condition is associated with the falling of the 
cord about the fifth or seventh day post partum. It is insidious in character, 
consisting of a general sanguineous oozing from the umbilical stump. The blood 
shows little tendency to coagulate. When the hemorrhage is not fatal, its 
tendency is to spontaneous arrest within a few hours or at most days. Other 
hemorrhages may coexist, as may also other neonatal diseases, and in some 
cases omphalorrhagia is simply a collateral phenomenon of syphilis neonatorum 
or umbilical sepsis. The prognosis is almost hopeless, as the escape of blood is 
with difficulty checked, and, moreover, death often occurs even after the bleed- 
ing vessels have been completely ligated ; suggesting that the fatal termination 
is due not to the escape of blood, but to the basic condition which makes the latter 
possible. The best treatment is probably compression with hare-lip pins, which 
will do all that can be done by hemostatic procedures. In this connection it 
may be mentioned that fatal omphalorrhagia may result from failure properly 
to ligate the cord at birth. Fortunately, omphalorrhagia occurs very rarely. 

2. Melena, or Gastro-intestinal Hemorrhage. — Hemorrhage from the capilla- 
ries is more frequent in infancy than at any other period of life. Hemorrhage — 
generally capillary — from the gastro-intestinal mucous surface occurs sufficiently 
often in the early days of life to make it a disease of some importance. It 
rarely occurs after the twelfth day. Etiology: No satisfactory cause has yet been 
assigned, but the hemorrhage is due, no doubt, to changes in the blood or in the 
blood-vessels or in both. Various authorities claim that the condition is due to 
circumstances attending birth, especially to too speedy ligation of the cord, to 
irritant materials in the intestine, to external violence, and to either a plethoric 
or a feeble state. There is reason to believe also that a tardy or incomplete 
establishment of the respiratory and circulatory functions, giving rise to venous 
stasis, is an important factor in an etiolog'cal way. Hereditary syphilis is 
associated with a small percentage of cases. A microbic theory has been 
advanced but not accompanied with testimony sufficient to be of value. It 
develops at any time during the first week of life and is fatal in 50 per cent, of 
the cases. Like other hemorrhages it may be traumatic or secondary to syphilis, 
sepsis, etc., but is often spontaneous or an expression of a general disposition 
to hemorrhage. In three cases described by Brothers, omphalorrhagia coex- 
isted in all. Pathology: Many cases show no lesion at autopsy except the 
hemorrhage and the blanching of the involved mucous membranes. There may 
also be ecchymoses of the mucous membrane. Ulcers are found in the stomach 
and intestine in a small proportion of cases. These ulcers are multiple and small, 
usually superficial, but may extend to the muscular coat or even perforate the 
intestine. The cause of these ulcers is somewhat obscure, but some are prob- 
ably of infectious origin, while others are due to thrombi in the blood-vessels of 
the mucous membrane. In a case in my service at the Emergency Hospital, 
blood was vomited and passed by rectum. The autopsy disclosed no ulcers 
of the stomach or intestines. Death occurred on the tenth day post partum. 
Symptoms: The presence of blood is generally the first symptom to attract 
attention, and blood in the stools is much more common than hemorrhage 
from the stomach. The general condition of the infant may be good or there 



916 THE PATHOLOGY OF THE NEWLY BORN. 

may be pale skin, feeble heart action, and decided weakness. Vomited blood 
is usually dark in color and small in quantity, the stools are always dark, the 
blood and fecal matter being closely associated. Clots in the stools are not 
■common. Occasionally death follows internal hemorrhage and the condition is 
discovered only at autopsy. It should be remembered that vomiting of blood 
may result from nursing from a fissured nipple. The prognosis depends upon 
the general condition of the infant and the frequency and amount of the hemor- 
rhages. The mortality has been estimated as high as 50 per cent. Treatment: 
General measures, such as proper food and appropriate stimulation directed 
to the maintenance of the bodily strength, should be resorted to. Astringents, 
either by mouth or per rectum or subcutaneously, have no influence upon the 
bleeding. Suprarenal extract given by mouth is held to be of benefit. 

3. Miscellaneous Hemorrhages. — Other localizations of this general hemor- 
rhagic tendency are (3) the subcutaneous tissue (purpura hemorrhagica), the 
extravasations occurring by preference over regions exposed to pressure; uncom- 
plicated purpura is a benign affection, although the loss of blood may be con- 
siderable. (4) The urinary passages (hematuria) and (5) the female genitals, 
where the escape of blood suggests precocious menstruation (see page 916). 
Finally, almost any locality may be the seat of hemorrhage, although the more 
infrequent, the more likely is the bleeding to be secondary to a local lesion. 
As already stated, the peculiar tendency to primary hemorrhage is expressed 
chiefly by omphalorrhagia, melena, or purpura, and often by the coexistence 
of two or more of these. In the management of all these hemorrhages of the 
newly born a few general principles may be isolated. Something may be done 
by general regimen, as the children are often feeble or premature. Bleeding 
surfaces which can be reached are to be treated by surgical hemostasis and 
astringents. In internal hemorrhage little can be accomplished by drugs or 
attempts at local medication, and our reliance must be placed upon rest, cold 
applications, and possibly ergot. 

4. From Genitals in Female Infants. — This hemorrhage may be a symptom 
of a number of very different conditions. In many instances the phenomenon 
appears to be physiological, and more than once it has foreshadowed precocious 
menstruation and early sexual development (St. Hilaire and others). In these 
quasi-menstrual cases the flow of blood begins a short time after birth and 
continues over a space which corresponds to a menstrual epoch. There is, 
.however, no recurrence on the following month. In other cases it appears to 

have a sinister meaning, for it has been noted as a terminal phenomenon in 
infants dying shortly after birth, especially premature infants. Doleris * looks 
upon such cases as examples of a general infection of doubtful origin, and in 
one such instance found a pericardial effusion from which he cultivated staphy- 
lococci. 

A series of autopsies would doubtless throw light upon the nature of this 
affection, or group of affections, but few such records exist. In one case of 
prematurity Eross found blood in the uterine cavity, and an apparent condition 
of hemorrhagic metritis. We may at the present day distinguish between a 
physiological, benign type of hemorrhage, and another form which appears 
to stand in relation with the uterine congestion of prematurity. It is also 
quite probable that other conditions may produce this phenomenon. I have 
observed during the past ten years a number of cases of muco-sanguinolent 
discharge from the vagina in full-term healthy children. Mothers and nurses 
* " Jour, de med. de Paris," 189S, x, 349. 



DISEASES OF UNKNOWN NATURE. 917 

are often unduly alarmed at its occurrence. A mild boric-acid wash is all the 
treatment called for. 

In addition to the hemorrhagic state and icterus which might well be placed 
under this head, there are a number of other affections — sclerema, Buhl's disease, 
Winckel's disease, mastitis, etc. It is impossible to state whether the leading 
element in these cases is readjustment, infection, or the persistence of some 
intrauterine affection. 

5. Sclerema neonatorum is an affection characterized by extremely low 
temperature and induration of the subcutaneous tissue (Fig. 1041). According 
to one theory, the latter phenomenon, representing a solidification of the sub- 
cutaneous fat, is readily explained by the former; but such a pathogeny is 
almost too simple to be credible. The subject of sclerema is in a hopeless state 
of confusion. It appears to attack the subdeveloped child only, but is much 
too rare to be ranked as a mere anomaly of readjustment. It is not necessarily 
a disease of the newly born, and hence can hardly represent the persistence 
of a fetal state. It cannot be brought into relationship with any infectious 
process. The peculiar induration first "appears in localities where adipose tissue 
is abundant, and usually extends over most of the subcutaneous area. At the 
same time there is a marked lowering of temperature with failure of circulation, 
cyanosis and oedema often appearing. The child seldom lives over three or 
four days from the inception of the 



<# 


-:"0 












u 


ill 


- -. 


*m 


Pi 


(M 


, 








^m 


mm. 



malady. While the general prog- 
nosis is grave, mild cases of scle- 
rema are sometimes saved by the 
treatment for prematurity, includ- 
ing the incubator. In a certain 
number of cases sclerema has been 
noted as a mere terminal stage of 
exhaustion. There is a large amount 

of evidence that the affection repre- FlG " "^.-Sclerema of the Newly Born. 

v —(Browning.*) 

sents only a high degree of the 

defective readjustment of the subdeveloped child. Unfortunately all sorts of 

exceptions to general rules have been noted. Ballantyne even cites a case in 

which no adipose layer was present. 

6. BuhPs Disease. — This term, which is more simple than the technical 
one "fatty degeneration of the newly born," suggests an infection, just as 
sclerema appears to depend upon prematurity or anomalous readjustment. 
The pathogeny, however, is obscure. The chief lesions are fatty degeneration 
of the heart, liver, kidneys, and other viscera. The hemorrhagic state and 
icterus may coexist. Buhl's disease, which is very rare, appears to stand in 
no relationship with prematurity, but has often been noted in healthy infants 
who have become asphyxiated intra partum. The navel is usually healthy, 
which excludes the presence of ordinary sepsis. From the clinical standpoint 
a baby reanimated after ordinary intra-partum. asphyxia gradually develops 
vomiting, icterus, oedema, the hemorrhagic state, and, as a natural result, 
inanition and exhaustion. The course of the affection is apyretic. Death occurs 
almost invariably and within two weeks. The hemorrhagic state, when well 
developed, is alone sufficient for a fatal termination. The treatment is 
symptomatic. 

7. Winckel's Disease. — This affection is also known as epidemic hemo- 

* "Dorsal Sclerema Neonatorum," William Browning, "Journal Cutan. and Gen.- 
Urin. Diseases," vol. xviii, whole No. 219, Dec., 1900. 



918 THE PATHOLOGY OF THE NEWLY BORN. 

globinuria of the newly born and in many respects resembles the preceding. 
It is evident that when a newly born infant receives a certain degree of shock 
or injury, the fact is declared by a general failure of the vital functions. Hence 
there is a certain resemblance in the phenomena which accompany sepsis, the 
disease under discussion, syphilis, and other states. Winckel's disease suggests 
infection even more than Buhl's, as it may occur in epidemics ; but its pathogeny 
is obscure. The lesions are not numerous or well defined, the most striking 
phenomenon being the state of the blood, the erythrocytes being completely 
disintegrated. The liberated hemoglobin tends to leave the blood through the 
kidneys, clogging the latter; it also accumulates in the spleen. Clinically the 
disease attacks healthy infants several days after birth, and the onset is very 
sudden, the patient seldom living beyond the second day. The most striking 
symptoms are the development of cyanosis from destruction of the oxygen- 
carriers, intense icterus, and exhaustion. From a diagnostic standpoint the 
most valuable symptom is hemoglobinuria. Death occurs usually from coma 
or convulsions. Winckel's disease is practically fatal, although, as in most 
epidemics, individual cases may be infected so mildly that recovery is possible. 

The treatment is entirely sympto- 







matic. 

8. Mastitis. — Mammary abscess 
belongs under "sepsis neonatorum," 
but the condition usually referred 
to as mastitis includes the condi- 
tion of physiological activity so 
often seen in children of both sexes 
at birth, by virtue of which milk is 
for a few days secreted in minute 
amounts (Fig. 1042). As a result of 
handling, want of cleanliness, etc., 
pyogenic germs may gain access to 
Fig. 1042.— Bilateral Mastitis of the these secretins p-1anrk anrl local 
Newly Born.— (Author's case at the Enter- tneSe secretm g glands and local 
gency Hospital.) sepsis may result. (See Sepsis.) 

The existence for two or three 
weeks after birth of mammary secretion is generally thought to be physiological. 
In any event, it is quite common. It is found as frequently in boys as 
in girls, the amount not often exceeding a few drops. Its chemical con- 
stituents are like those of adult milk. The condition of functional activity 
will generally disappear spontaneously. Treatment: In the majority of cases no 
treatment is necessary. When the glands are really inflamed, an application of 
ichthyol ointment, 20 per cent., lead-water and laudanum, or lead plaster may 
be made. In the event of pus formation immediate incision and evacuation 
are indicated, together with supporting and stimulating treatment. 

9. Jaundice. — Icterus neonatorum may also be included among anomalies of 
readjustment, although in certain cases it is a complication of sepsis, etc. The 
pathogeny of primary icterus is obscure, although this affection occurs so fre- 
quently that it may almost be regarded as physiological. It is often associated 
with uric-acid infarcts in the kidney. Primary icterus appears during the first 
week of life and lasts but a few days. It does not begin in the conjunctivas, 
which are involved after the skin. The child loses weight during the evolution 
of the disease. It is almost impossible to differentiate primary icterus from 
the jaundice which accompanies sepsis, syphilis, malformations of the hepatic 
tissues, etc. Nor is it possible to distinguish between a primary icterus from 



GENERAL POST-PARTUM CONDITIONS. 919 

anomalous action of the liver and a hypothetical hematogenous form. Jaundice 
of the newly born might also be of fetal origin in certain cases, and under these 
circumstances the pigment would come from the mother. Little or no special 
treatment is required, although syrup of rhubarb and calomel are often admin- 
istered. 



VII. GENERAL POST-PARTUM CONDITIONS. 

I. Ulceration of the Hard Palate, Bednar's Disease. 2. Sublingual Cysts, j. Vomiting. 
4. Colic. 5. Diarrhea. 6. Constipation. 7. Intestinal Obstructions. 8. Pneumonia. 
q. Convulsions. 10. Infantile Cachexia. 11. Sudden Death. 12. Medication of the 
Newly Born. 

i. Ulceration of the Hard Palate, Bednar's Disease. — This is characterized 
by the formation upon the hard palate of two ulcers, one on each side of the 
median line; occasionally only one may be present. They are at first super- 
ficial. It is supposed to be caused by friction against the rubber nipple, by 
the habit of tongue- sue king, or by rough and careless manipulations in cleansing 
the child's mouth. Marasmus is a predisposing cause. The treatment is 
removal of the cause if possible. If marasmus or malnutrition is present, a 
cure may be difficult or impossible. 

2. Sublingual Cysts. — What is known as the lingual duct is represented by 
a canal running from the foramen caecum between the geniohyoglossi muscles 
to the posterior surface of the hyoid bone. In its course cysts may develop, 
due no doubt to an inclusion of a minute portion of epiblast or hypoblast. 
They are always congenital, but may not become manifest for many years, 
when they may become attached to the hyoid bone behind or to the lower 
jaw in front. The dermoid variety are lined with epithelium and contain 
sebaceous matter and sometimes hairs. Another variety, by far the most 
important, is ranula, a bluish, semi-transparent, ovoid or round swelling with 
thin walls located in the floor of the mouth under the fore part of the tongue. 
They are usually unilateral, contain glairy, mucoid material, and are painless. 
As a rule, they are small, but they may attain the size of a walnut and so inter- 
fere with speech and swallowing. The typical ranula is most frequently a 
retention cyst of the mucus-secreting glands of the floor of the mouth. The 
treatment is entirely surgical. Radical extirpation is practised for dermoids, 
while incision and cauterization are the methods most commonly employed for 
the cure of ranula. 

3. Vomiting. — Regurgitation of food is sometimes due to the fact that the 
child is fed too often or in too large quantit} r . Thus regurgitation is of 
frequent occurrence. In other cases, and especially if the vomited matter 
contains curds, some defect in the preparation or composition of the milk is to 
be suspected. 

4. Colic. — One of the most common symptoms which the physician is called 
upon to treat is colic. Too often the symptom alone is treated without proper 
consideration of the etiological factors in the case. Etiology: Some error in 
diet is almost always the underlying cause. In a great majorit}^ of cases it 
is the proteids of the milk, although any of its constituents may be at fault. 
Flatulence follows, due to the formation in the intestine of gas from fermenta- 
tion or decomposition, and colic ensues. All severe forms of intestinal inflam- 
mation, chilling of the body-surface, or a diet containing cereals in excess are 
prominent causes. When colic is unaccompanied by flatulence, the pain is due 
to muscular spasm. It occurs in breast-fed as well as bottle-fed children, and is 



920 THE PATHOLOGY OF THE NEWLY BORN. 

most common during the first three months. The pain is often severe. Symptoms: 
A child with colic presents a picture which is almost characteristic. The facial ex- 
pression is one of misery, crying is violent and paroxysmal, as a rule the lower 
extremities are drawn up, the abdomen is tense and hard and more or less 
tympanitic, and in severer cases there is cold, clammy skin, with feeble pulse 
and possibly convulsions. The expulsion of flatus is followed by almost imme- 
diate relief. The possibility of intussusception or appendicitis must be borne in 
mind. Treatment: Recalling the fact that flatulence is the predominant cause, 
an enema affords the greatest hope of speedy relief. From three to eight 
ounces of lukewarm water or a smaller quantity of sweet oil or glycerin is 
ordinarily effectual. Heat to the abdomen and feet is of value. Turpentine 
stupes to the abdomen are always grateful. When relief is afforded, it is wise 
to purge with fractional doses of calomel or a mild saline. When the muscular 
spasm is severe, opiates are indicated A study of the patient's digestive 
powers and scientific modification of its food are demanded when attacks of 
colic show a tendency to recur. During the attack a drachm of soda-mint or 
a few drops of gin or brandy in a little warm water, or a few drops of compound 
tincture of cardamom, may afford relief. 

5. Diarrhea. — Several varieties of this ordinary affection of infancy have 
been described, but an elaborate classification seems unnecessary, since many 
factors both in a causative and curative way are common to the various forms. 
Three or four movements a day, if normal in consistency and in color, need excite 
no apprehension. If the passages are greenish and contain undigested particles, 
attention should be directed to the feeding. Etiology: Young infants are very 
susceptible. The greatest number of cases * occur in the first eighteen months 
of life, because conditions which make no impression in later life often increase 
the number of stools in infants. Breast-fed children furnish the smallest per- 
centage of these cases, while artificial feeding is responsible for the majority. 
Summer is the season in which the disease is most prevalent. It should be 
borne in mind that although uncleanliness, crowded apartments, and lack of 
proper food predispose in a great measure to this affection, they are not causes, 
since severe forms of the disease occur in the most desirable environments 
and under the most favorable conditions of medical attention. Impure milk is 
a common cause. Too frequent and abundant feeding, dentition, exposure to 
cold and fright, or strong mental impressions are other causes. Symptoms: 
Diarrhea develops suddenly when due to exposure or improper alimentation, 
but at times prodromal symptoms, such as restlessness, colicky pains, or nausea 
and vomiting, may precede the attack for several days. The stools vary much 
in size, color, and consistency. In infants they are apt to be green and 
foul, numbering from four to sixteen in the twenty-four hours, and con- 
taining lumps of fat and coagulated casein. Loss of weight usually occurs, 
depending upon the height of the fever and the intensity of the process 
in the intestine. If the stools are frequent, thirst is common. Treatment: To 
remove all irritant matter from the intestine is the first feature which requires 
attention. A purge with castor oil, calomel, or a saline should be given. At 
times a high injection of a quantity of decinormal salt solution, with or without 
some mild astringent, — witch-hazel, for example, — is an effective adjunct to 
catharsis. When a thorough evacuation has been accomplished, some prepara- 
tion of opium may be given to lessen peristaltic activity. During the attack 
the diet should be very limited; in some cases nothing but very moderate 
quantities of water, plain or in combination with egg-albumen or barley, should 

* Crandall. 



GENERAL POST-PARTUM CONDITIONS. 



921 



Fig. 1043. — Glass 
Rectal Syringe. 



be administered in the first twenty-four or forty-eight hours. When the condi- 
tion of the patient warrants, the diet should be gradually increased. Plenty 
of pure water must be given. If diarrhea continues and bids fair to be exhaust- 
ing, two to four drops of paregoric, with four drops of 
aromatic sulphuric acid or gr. iij to v bismuth subnitrate, 
may be tried. The paregoric should not be repeated, 
however, until the effects of the first dose have entirely dis- 
appeared. The bismuth may be repeated as indicated. 

6. Constipation. — The term constipation in young chil- 
dren signifies any delay beyond the normal period in the 
passage of fecal matter. Etiology: Anatomically the for- 
mation and disposition of the colon predispose to constipa- 
tion. Its relative length is greater than in the adult, its 
walls are relatively weaker, and their physiological activity 
is not fully developed. Congenital abnormalities, such as 
narrowing of the lumen of the gut, are rare causes in 
infancy. Among the exciting causes, which include defi- 
cient glandular secretion, excessive perspiration, inflam- 
matory conditions, and frequent purgations, we find that 
improper feeding and lack of general muscular tone furnish 
the majority of cases. The mother's milk may be defi- 
cient in fats, while artificially prepared foods are not only 
lacking in the proper amount of fat, but are also often 
too easily digested, leaving but little residue to form the 
basis of a proper stool. Too great a quantity of proteids 

or an insufficient fluid supply will also lead to constipation. Rickets is a 
potent cause. Symptoms: The number and character of the stools in each 
twenty -four hours give the most reliable information concerning the alimentary 
processes. In the newly born one or even two or three stools each day do not 
preclude the existence of constipation when the move- 
ments are drier and firmer and more lumpy than normal 
and are expelled by straining. When daily stools do not 
occur without medicinal or mechanical assistance, other 
symptoms may arise, as flatulence, distention of the abdo- 
men, colicky pains, restlessness, disturbed sleep, and even 
high fever, convulsions, and much prostration. Hernia 
and prolapsus ani may be resultant phenomena. Treat- 
ment : The attention of the mother or nurse should be 
directed to the formation of a regular habit; even very 
young infants seem to appreciate the motive of being 
placed in the chair at certain daily intervals. The method 
of feeding should be investigated and the cause removed 
if possible. Constipation may be due to the presence of 
too little fat or too much proteid matter in the food. 
The introduction of a suppository of pure castile soap is 
a simple and usually effective way of causing a movement, 
since in most cases the trouble is due to the presence of a 
rather hard fecal mass in the rectum. If the continued 
use of the soap suppository causes irritation, the domestic 
resource, a cone of oiled paper, may be used. The prolonged use of glycerin 
suppositories may cause considerable irritation and even inflammation. The 
habit of regular movement may be cultivated by giving the child a supposi- 




Fig. 1044. — Rubber 
Rectal Syringe. 



922 THE PATHOLOGY OF THE NEWLY BORN. 

tory at a certain hour each day. If it becomes necessary to give an enema, 
not more than half an ounce of pure castile soap and water should be given, 
since the rectum in young children is relatively small. When water is not 
effective, the injection of a little sweet oil may be promptly successful. When 
suppositories or enemata are ineffectual, a drachm or two of sweet oil by the 
mouth is sometimes useful. Much benefit may often be derived from the 
administration of fifteen drops of cod-liver oil three times a day. An effort 
should be made to regulate the bowels by attention to food and by the use of 
suppositories, and by dispensing as far as possible with the use of laxative 
medicines. Castor oil should not be given in the habitual constipation of 
infants. If medicine becomes necessary, a few drops of the fluid extract of 
cascara sagrada may be given, or a little milk of magnesia. Massage of the 
abdomen is often useful. 

7. Intestinal Obstruction. — The majority of these cases occur during the first 
year of life, and the prompt recognition and treatment of the condition are 
most important. Etiology: In the newly born, malformation — such as imperforate 
anus, occlusion of the rectum, or maldevelopment of any portion of the intestinal 
tract, more often of the duodenum — plays an important part. During the first 
six months of life intussusception is responsible for one-half of the cases. The 
great liability to intussusception in infancy is due partly to the anatomical 
character of the intestine during this period of life and partly to the fact that 
there are more frequent inequalities in the intestinal movements than in older 
children. In the infant the walls of the gut are thin and poorly developed 
and the mesentery and mesocolon are proportionately longer than at a later 
period of life. The ileocecal is the most frequent form of intussusception, and 
males suffer from this more frequently than females. Volvulus and obstruction 
due to tumors are rare in early life. Pathology: When intussusception occurs, 
traction on the mesentery leads to obstruction of the blood-vessels in the intes- 
tine, causing congestive oedema and hemorrhage. Above, the gut is swollen 
and distended; below, it is flaccid and empty. Gangrene and sloughing may 
occur and portions of the gut be passed through the rectum. Perforation is 
not infrequent and local or general peritonitis follows. Symptoms and diag- 
nosis : The symptoms var}^ according to the age and the character and site of 
the obstruction. When no stools occur, examination with the finger or with 
a bougie readily determines the rectal condition. When the obstruction is 
higher up, the diagnosis is more difficult. When intussusception occurs, pain 
in the abdomen, usually paroxysmal, is one of the first and most conspicuous 
symptoms. Vomiting is rarely absent. Scanty evacuations of blood unmixed 
with fecal matter are the ordinary stools of intussusception. Tumor is an 
important symptom; it often occurs a few hours after the onset of the attack, 
and may be felt either through the abdominal walls or per rectum. The general 
symptoms are those of prostration and collapse. Treatment: The proper treat- 
ment of intussusception consists in efforts to reduce the displacement by pressure 
from below. Two methods, inflation and injection, are employed. Inflation 
should be practised under an anesthetic, the amount of air introduced being regu- 
lated by the amount of tension of the abdominal walls. Injections of lukewarm 
water are given, the buttocks being elevated to aid the entrance of the fluid into 
the bowel. Reduction is generally followed by gurgling sounds and the expul- 
sion of flatus, with quick relief from all distressing symptoms. Laparotomy 
must be resorted to at times. For the congenital causes of intestinal obstruction 
surgical treatment is necessary. 

8. Pneumonia. — (See Acute Infectious Diseases, page 873.) 






GENERAL POST-PARTUM CONDITIONS. 923 

9. Convulsions. — The term convulsions is here employed to designate the 
bodily conditions characterized by acute seizures, clonic, rhythmic, sometimes 
violent, generally involving one set of muscles, or the entire muscular system, 
with unconsciousness as a usual accompaniment. They occur as a symptom in 
a great variety of diseases, but here only those occurring in infancy will be con- 
sidered. Etiology: Infancy itself is the great predisposing cause. The infant 
cerebrospinal system is easily impaired and deranged, and readily loses its 
equilibrium, especially during the period of its most active development. Some 
children inherit susceptible nervous temperaments. In older children rickets 
is the most prominent predisposing cause. Of the exciting causes, some irritant 
in the alimentary canal, due to transitory changes in the mother's milk, or to 
improper food, is the most frequent and leads to gastric or intestinal indigestion. 
The irritant may produce convulsions reflexly, but authorities are now practi- 
cally agreed upon the adoption of the toxic theory as the proper explanation. 
The onset of pneumonia and scarlet fever, more rarely measles and diphtheria, 
is often marked by convulsions. Atelectasis, meningitis, and meningeal and 
cerebral hemorrhage are direct causes. Whooping-cough furnishes a moderate 
percentage of cases. Dentition is an extremely rare cause. Retention of urine 
and phimosis are sometimes directly responsible. Symptoms: General convul- 
sions do not differ materially from ordinary epileptic seizures so far as the 
infant's appearance is concerned. In some cases prodromal signs of restlessness 
and irritability may give warning, but most often the attack comes on sud- 
denly. The face is pale or cyanosed, the head is thrown back, the eyes 
roll or are staring, the hands are clenched with thumbs adducted to the palms, 
then twitchings of the eyelids or the face or of one extremity are soon fol- 
lowed by clonic movements of the entire body. Foaming at the mouth is 
common, the heart is rapid and weak, the pulse irregular, respiration embar- 
rassed, urine and feces may be voided involuntarily, and the entire body 
surface is covered with clammy perspiration. Gradually the convulsions 
cease and the child passes into a sleep or stupor, to be followed in most cases 
by one or more convulsions. Unilateral convulsions make one suspicious 
of a cranial lesion, while those occurring with fever of 103 to 106 F. are 
suggestive of the onset of acute infectious disease. Treatment: This is first 
directed to the controlling of the spasms. Baths at a temperature of 105 
to no° F., given for from five to fifteen minutes, are the most effective means 
at our command. In infants under four months of age the skin is tender and 
plain water is sufficient, but in older infants mustard — a handful to four gallons 
of water — will enhance the effectiveness of the baths. In severe cases the temper- 
ature of the bath should be increased toii2°orii5°F., and the child immersed 
for at least ten minutes. Friction of the entire body, but particularly to the 
extremities, should be performed. After the bath the infant should be wrapped 
in a warm blanket and placed on its right side to relieve the overburdened 
right heart. An ice-bag to the head and hot bottles to the feet are always 
useful. Chloroform by inhalation is necessary at times in older children, and 
chloral hydrate and sodium or potassium bromide per rectum in proper doses 
are useful and powerful sedatives. As soon as the convulsion is controlled an 
enema should be given to insure a thorough action of the bowels. A purge 
is always indicated, and castor oil is the best of that class. Up to the age 
of five months the administration of one-half teaspoonful will ordinarily be 
followed by good results. If there is much prostration, whisky in ten to thirty 
minim doses should be given every two or three hours. 

10. Infantile Cachexia. — A common affection of infancy is considered under 



924 THE PATHOLOGY OF THE NEWLY BORN. 

the title of infantile cachexia. Failure to obtain and assimilate the proper 
amount of nourishment is the secret of this condition, and its occurrence with 
few or no appreciable digestive disorders demands for it the earliest possi- 
ble recognition. Synonyms are marasmus; infantile atrophy; simple wasting. 
Etiology : The majority of cases are due to limited or improper food-supply, not 
sufficient to counterbalance the metabolic waste occurring in the body tissues. 
Symptoms: In early infancy the loss in weight is generally the first symptom 
to attract attention, and this may occur when nothing else abnormal is noted. 
Fever may be present in mild or severe degree, and then the loss in weight 
is proportionately rapid. In well-marked cases the appearance is quite charac- 
teristic. The infant's expression is drawn, the skin is pale and dry or covered 
with clammy perspiration, the extremities are cold, the child is fretful and drowsy 
alternately. No healthy disposition to take food is shown, or when taken 
it is almost immediately vomited. Constipation is generally present, but 
greenish stools with curds are often seen. Diagnosis: When the organic dis- 
eases of the stomach, intestines, liver, kidneys, heart, and brain are excluded, 
it should be borne in mind that one-half of the cases are due to improper feeding, 
with environment and constitutional disturbances as contributory elements. 
Prognosis: The very young are inclined to lose ground rapidly, but older infants 
offer rather more hope of recovery. As a class the ultimate results are difficult 
to determine. Inability to retain food, fever, and imperfect circulation all tend 
to render the prognosis more unfavorable. Sudden death is not an uncommon 
termination. Treatment-: Attention should at once be directed to furnishing 
food proper in quality and quantity to sustain the infant. When the mother's 
milk is at fault, a wet nurse should by all means be secured, for in this condition 
more than any other does the use of human milk find its greatest indication. 
Water should be given plain or with egg-albumen or sugar to help increase 
the body- weight. When fever is present, tepid baths reduce it satisfactorily 
and gentle rubbing will keep up the peripheral circulation. Liquid peptonoids, 
or panopeptone, often agree very well with infants, having a supporting in- 
fluence. 

ii. Sudden Death of the Newly Born. — In infants who present no visible 
external changes sudden death is not an infrequent occurrence. The excita- 
bility of the nervous centers in the young and their violent response to con- 
ditions incapable of serious results in older persons tend to make this subject 
one of extreme interest, especially in a medico-legal way. It is generally due 
to one of the following causes: Asphyxia occurs from over-lying in bed, from 
particles of food lodged in the larynx, or from an enlarged thyroid gland pressing 
upon the trachea or pneumogastric nerve. Of the infants who are born in a state 
of asphyxia and respond to methods of resuscitation, about 4 per cent, die within 
three days after birth and autopsy reveals a condition of atelectasis. Convul- 
sive disorders : Seven per cent, of sudden deaths are referred to this cause. In 
infants, in nine cases out of ten, convulsions are due to some irritant in the 
alimentary canal; in older children rachitis is the great underlying cause. 
Cranial hemorrhage is also a cause of convulsions, but children rarely die sud- 
denly from it. Infantile cachexia: This is one of the common causes, and heart 
failure is the most probable cause of death, since real lesions are rarely found at 
post-mortem examination. Internal hemorrhage: Hemorrhage into the brain, 
lungs, pleura, stomach, intestines, or any of the abdominal organs gives symptoms 
of sudden collapse quickly followed by death. This occurs very early in life, 
the infant seemingly being affected by the sudden change from intrauterine to 
extrauterine existence. Pulmonary congestion: This may complicate any sudden 



GENERAL POST-PARTUM CONDITIONS. 925 

and great rise of temperature and cause death in a few hours. In the acute 
infectious diseases, particularly bronchopneumonia, a certain number of infants 
are overwhelmed by the intensity of the intoxication. As other causes of 
sudden death may be mentioned congenital malformations of the principal 
bodily organs, such as hernia, hydrocephalus, patent foramen ovale or ductus 
arteriosus, defects in the ventricular septum, diaphragmatic hernia, narrowing 
or occlusion of the stomach or intestines, imperforate anus, and abnormalities 
of the kidney and ureter. 

12. Medication of the Newly Born. — The infant is often treated through the 
mother, but the amount of a drug which reaches the former through the milk 
is now believed to be too insignificant to produce therapeutic results. It there- 
fore becomes necessary at times to administer medicines directly to the newly 
born. Stimulants : These have a very wide field, being indicated in the nu- 
merous severe septic affections as well as in prematurity and general debility. 
The dose is i to 3 drops of whisky hourly, increased in septic cases. Seda- 
tives : In case of colic or other pain which resists attempts to regulate the 
diet, etc., a mild opiate may be given (paregoric, 1 to 5 *K). The bromides 
and chloral are useful per rectum. Stomachics: For indigestion, flatulence, 
colic, etc., carminatives are indicated, with small doses of calomel ( T V grain 
every three hours). Antacids are also useful (soda, magnesia), as also is 
pepsin. Laxatives: When mild remedies like sugar will not suffice, calomel, 
castor oil, and cascara sagrada are most effective. Diuretics: Sweet spirits 
of niter is the remedy usually chosen to produce diuresis in the newly born. 
Local remedies: The toxic antiseptics should be used well diluted, if at all (e. g., 
corrosive sublimate 1 : 10,000). Boric acid is preferable, as a rule, to the 
poisonous drugs. Counterirritation is practised chiefly for colic and vomiting, 
in the form of a spice poultice over the abdomen. 



PART TEN. 

Obstetric Surgery* 



(A) INTRODUCTION. 

I. PREPARATIONS FOR OPERATION. II. DECINORMAL SALINE SOLU= 

TION INJECTIONS. III. ANESTHESIA IN OBSTETRICS. IV. POS- 
TURE IN OBSTETRICS. V. VAGINAL EXAMINATION. VI. DIGITAL 
EXPLORATION OF THE UTERUS. VII. VULVAL DOUCHE. VIII. 
VAGINAL DOUCHE. IX. INTRAUTERINE DOUCHE. X. VAGINAL 
TAMPON. XL UTERINE TAMPON. XII. PASSING THE CATHETER. 

(B) OPERATIONS PREPARATORY TO DELIVERY. 

II. ARTIFICIAL RUPTURE OF MEMBRANES. II. INDUCTION OF ABOR= 

TION AND PREMATURE LABOR. III. MANUAL DILATATION OF 
THE CERVIX. IV. INSTRUMENTAL DILATATION OF THE CERVIX. 
V. MANUAL AND INSTRUMENTAL DILATATION OF THE VAGINA 
AND VULVA. VI. INCISIONS OF CERVIX, VAGINA, AND VULVA. 

VII. CORRECTION OF FAULTY POSTURES, MALPOSITIONS, AND 
MALPRESENTATIONS. VIII. VECTIS. IX. FILLET. X. REPOSITION 
OF PROLAPSED SMALL PARTS, FOOT AND CORD. XI. VERSION. 
XII. PELVIOTOMY. XIII. SYMPHYSEOTOMY. XIV. EMBRYOTOMY 
IN GENERAL. XV. PERFORATION. XVI. RACHIDOTOMY. XVII. 
CRANIOCLASM. XVIII. CEPHALOTRIPSY. XIX. DECAPITATION. 
XX. EVISCERATION. XXI. AMPUTATION OF EXTREMITIES. XXII. 
CLEIDOTOMY. XXIII. SPONDYLOTOMY. 

(C) OPERATIONS FOR DELIVERY. 

III. EXPRESSION OF THE FETUS, EXPRESSIO FCETUS. II. FORCIBLE 

DELIVERY, ACCOUCHEMENT FORCE. III. MANUAL EXTRAC= 

TION OF THE FORE=COMING HEAD. IV. SHOULDER EXTRAC= 
TION IN HEAD=FIRST LABORS. V. BREECH EXTRACTION. VI. 
EXTRACTION OF THE AFTER=COMING HEAD. VII. FORCEPS. 

VIII. SLING OR SOFT FILLET. IX. BLUNT HOOK. X. CROCHET. 
XL EXTRACTION OF THE FETUS MUTILATED BY EMBRYOTOMY. 
XII. CESAREAN SECTION. XIII. VAGINAL CESAREAN SECTION. 
XIV. PORRO C/ESAREAN SECTION. XV. POST=MORTEM C^ESA= 
REAN SECTION. XVI. CELIOTOMY FOR ECTOPIC GESTATION. 
XVII. DELIVERY OF PLACENTA AND MEMBRANES. Crede's Method. 
Dublin Method. Digital Extraction. Manual Extraction. Instru= 
mental Extraction. Curettage. 

(D) OPERATIONS FOR THE CORRECTION OF INJURIES. 

IV. CELIOTOMY FOR RUPTURE OF THE UTERUS. II. CELIOTOMY FOR 

SEPSIS OF THE UTERUS. III. REPAIR OF INJURIES TO CERVIX, 
VAGINA, RECTUM, PERINEUM, CLITORIS. 



(A) INTRODUCTION. 

The subject of obstetric surgery falls naturally into three divisions: The first 
embraces operations preparatory to delivery, such as the premature induction of 
labor; removal of the barrier of the cervix; correction of faulty presentations, 
attitudes, and positions; increasing the size of the pelvis by symphyseotomy or 
diminishing the size of the fetus by craniotomy or cutting operations on the 
trunk. The second division includes operations for delivery, such as expres- 
sion, manual and forceps extraction, Cesarean section, and various methods of 
placental delivery. In the third division fall the various operations for the 
correction or repair of injuries produced during labor. 

In considering the subject of obstetric surgery, my aim will be to give briefly 
and concisely an account of the best method of dealing with the various forms 
of dystocia, and an effort will be made to give in condensed form the gist of 
modern scientific teaching and of my own experience in each case. The dis- 
cussion of unconfirmed theories, disputed points, and measures of doubtful ex- 
pediency will be avoided as unsuited to a work of this character. 

Labor is a physiological process, and in normal cases the less interference 
the better. No consideration of time or convenience, or even the entreaties of 
the patient or her friends, should be used as an excuse for interference unless 
such interference is distinctly indicated in the interest of mother or child. 
Various abnormal conditions and causes, however, into which it is not now 
necessary to enter, may render operative interference not only justifiable but 
imperatively necessary. 

Primum non nocere is a principle not always easy to impress upon the under- 
graduate student. The student in his two or four weeks' course in practical 
obstetrics may possibly witness many obstetric operations and naturally draw 
the conclusion that interference in cases of confinement is of common occurrence, 
when we desire to impress upon the student's mind quite another picture. 
With a false impression the young physician enters upon his practice, and 
one unnecessary operation leads often enough to a long train of misfortunes. 
Unfortunately we see many examples of the foregoing. A primipara, for in- 
stance, has been in labor for twelve hours ; the membranes have ruptured several 
hours previously; the head rests upon a rigid pelvic floor; which latter renders 
the second stage slow; the fetal heart is good ; the mother is in excellent condition, 
and as yet there is no danger of damage to the soft parts, as the head has only just 
reached the pelvic outlet ; there is, therefore, no indication for interference. A hur- 
ried low-forceps operation is performed ; a third degree laceration of the pelvic floor 
results; a hurried operation for repair is done, which in the absence of proper 
assistance and ligatures gives a bad result. What follows ? A subsequent opera- 
tion must be performed by an expert, and in the mean time, and possibly after 
the second operation, should it too fail, the patient is doomed to rectal inconti- 
nence and becomes an exile from society, and all because in the first instance 
in the absence of a positive indication, a "harmless low-forceps operation" was 

927 



928 OBSTETRIC SURGERY. 

performed. Still another clinical picture presents itself. A pelvic presentation 
occurs in a multipara. One foot prolapses and appears at the vulva. Mother 
and fetus are in perfect condition. There is positively no indication for inter- 
ference, but the temptation is too great. In order to facilitate delivery, the 
attending physician seizes and makes traction on the prolapsed leg. What re- 
sults? The head, as well as one or both arms, becomes extended. Delay in the 
delivery of the extended arms and head causes death of the fetus. The difficult 
extraction results in deep laceration of the cervix extending into the folds of 
the broad ligament. Severe hemorrhage follows. A hasty tamponade of uterus 
and vagina, not under aseptic precautions, results subsequently in severe en- 
dometritis and parametritis. What is the termination of such a case? Death 
of the child, and the mother left with crippled pelvic organs, perhaps for life, 
all from an attempt to facilitate the progress of labor by traction upon a pro- 
lapsed leg. 

The student cannot have too often repeated to him the statement that 
obstetric operations of any kind should be undertaken only in the presence 
of a positive indication; that even what are apparently innocent operative pro- 
cedures in obstetrics may terminate in tragedies. The more impressed the 
student is with the full meaning of the term primum non nocere during his 
residence in the medical school and maternity, the more conservative and the 
better accoucheur will he become in his private practice, the better the fate of 
the mother and child entrusted to him, and the better his professional reputa- 
tion. 



I. PREPARATIONS FOR OPERATION. 

Patient. — Many obstetric operations may be performed with the patient placed 
across the bed in the lithotomy position, the buttocks being drawn to the edge. 
The flexed thighs are either held or, better, confined with a sheet or canvas crutch. 
Rubber sheeting or a Kelly pad and a pail are used for drainage (Fig. 1058). 
It is far better, however, in private practice, to improvise an operating table 
by pressing into use the kitchen, dining-room, or other table. This should be 
covered with an old blanket and a clean, freshly laundered bed-sheet, and a 
Kelly pad or a rubber sheet placed at the foot to drain into a pail or foot-tub. 
The patient should be anesthetized in bed and afterward placed upon the table 
in the lithotomy position, with thighs held in flexed position by a twisted 
sheet under the shoulders or a Clover crutch (Fig. 1089). The rectum must 
have been emptied by an enema. The external genitals should be scrubbed 
with soap, brush, and warm water. For all intrauterine or cutting operations 
the pubes and vulva should be shaved. A catheter should be passed and a 
final scrubbing with a sublimate solution (1 : 2000) or 1 per cent, lysol performed. 
The immediate field of operation should be surrounded with sterile towels. 
The vagina should be carefully washed out, before all intrauterine operations, 
with a 1 per cent, lysol or creolin solution. This should be done with the 
fingers, a cotton swab, or a jeweler's brush, never with a stiff brush, which 
would injure the vaginal mucous membranes. 

Instruments and Dressings. — The antiseptic agent's used in obstetrical practice 
are the same as those used in general surgery. Heat is the most useful and easily 
applied means for making dressings and instruments sterile. Dry heat is the 
least convenient form to use, since it takes longer to accomplish its purpose than 
does moist heat and is slow in penetrating to the interior of a bundle of dressings. 



DECINORMAL SALINE SOLUTION INJECTIONS. 929 

Moist heat may be used as steam at ordinary or increased pressure, or in the 
form of boiling water. Superheated steam does not penetrate much better than 
dry heat. Many hospitals use an instrument which subjects its contents to 
steam at about 250 F. (12 1° C.) at 15 pounds pressure, and this is found very 
efficacious for dressings and other materials. Boiling in plain water, or, better, 
in water to which about 1 per cent, of sodium carbonate or bicarbonate 
has been added, is an exceedingly convenient method of sterilizing instru- 
ments or anything which will stand the treatment. The addition of the soda 
prevents rusting and shortens the time necessary for boiling. Five minutes of 
active ebullition is enough. The soda should be chemically pure ; otherwise sub- 
stances might be present which would injure the instruments. In private practice 
obstetric instruments should be contained in canvas cases (page 519) or pinned 
in towels before boiling. They are then brought to the operating table on a 
dish without removing the towel and taken directly from the towel for use in 
the given operation. Trays and antiseptic solutions for instruments are thus 
dispensed with. 

Operator. — (See Asepsis in Obstetrics, page 153.) 



II. DECINORMAL SALINE SOLUTION INJECTIONS. 

INFUSION, ENTEROCLYSIS, HYPODERMOCLYSIS. 

On account of the great importance of this resource in obstetrics and the 
number of conditions for which it may be indicated — including eclampsia, hemor- 
rhage, and sepsis — I have thought it advisable to devote a special section to 
the general principles and technique of the various methods of exhibiting the 
saline solution. 

Preparation of the Solution. — The decinormal saline solution consists, roughly 
speaking, of a drachm of salt (sodium chloride) to a pint of water, but this 
simple formula has been modified in various ways. Water alone, provided that 
it is not distilled, may replace the salt solution in emergencies; and any propor- 
tion of salt will answer which does not exceed three times the proportion nor- 
mally contained in the blood. As a matter of fact, the solutions in use vary 
from -rV per cent, to -ro per cent. To prepare a solution with accuracy, forty-six 
grains are added to a pint of water, but in emergencies a small teaspoonful, 
not heaped up, will suffice. After the solution has been prepared it should 
be boiled and filtered. While the saline solution is supposed to be freshly pre- 
pared at the time of use, it is necessary in hospital practice to have it constantly 
on hand, and the custom which generally prevails is to prepare a concentrated 
solution which can be diluted as required. The solution must be exhibited at 
a certain temperature. While ioo° F. is the conventional temperature, some 
obstetricians prefer 105 to no° F. as representing a gain in stimulating proper- 
ties. 

Rectal Infusion. — From four ounces to a pint and a half of the decinormal 
salt solution, at a temperature of no° to 120 F., should be kept in the bowel 
continuously. Any of the usual rectal tubes may be used, but a soft-rubber 
catheter attached to the tube of a fountain syringe usually causes the least 
irritation. The patient may be placed in the dorsal or lateral position, and 
it is convenient to have the buttocks project a little over the edge of the bed. 
I have found that the left lateral posture with elevation of the hips favors 
retention of the solution, and is least objectionable to the patient (Fig. 1061). 
59 



930 



OBSTETRIC SURGERY. 



Indications: As a preventive or curative measure in cases of shock, especially of 
shock from hemorrhage. 

Intra-arterial Infusion. — The radial artery is the vessel usually chosen for 
infusion, on account of its accessibility. The skin is scratched over the artery 
as a guide, the limb is elevated, and a tourniquet is applied to the upper arm. 
The incision is i or 2 inches (2.5 or 5 cm.) long and crosses the artery obliquely. 
The vessel is carefully isolated, divided, and ligated at the central end. A 
cannula is then inserted into the peripheral end and tied in while infusion is pro- 
ceeding. The tourniquet is then loosened, and after the infusion is completed 
the cannula is withdrawn and the peripheral end of the vessel is also ligated. 
This form of intervention is too radical and complicated for routine use. 

Intravenous Infusion. — Indica- 






_»?- 



tions. — The indications for intraven- 
ous infusion are similar to those of 
other methods of exhibiting the salt 
solution. Generally speaking, it is 
the typical method, the others hav- 
ing a more limited field. In sepsis 
and eclampsia or toxemia in general, 
it is sometimes the custom to conjoin 
phlebotomy with infusion. The in- 
cision made for the cannula will 
suffice for the escape of the blood, 
which should average about a pint. 
In certain cases venesection is carried 
out in one arm and infusion in the 
other, the operations being syn- 
chronously performed. The reaction 
against the teaching of the past, that 
entrance of air into a vein is a fatal 
accident, is believed to be unwise. 
Fatalities certainly have occurred, 
and it is well to take all precautions. 
Experiments on animals show that- 
the rational treatment of air in the 
veins is the persistence in the process 
of infusion at no° F., with artificial 
L respiration. 

Technique. — The solution should 
be contained in a glass irrigating jar 
having a capacity of five pints or more. The flow should never exceed the rate 
of a pint in five minutes. The jar should be provided with a bath thermometer, 
and an apparatus for raising and lowering it to any desired height. While 
infusion is in progress it is well to wrap the irrigating j ar in a large, hot, sterile 
towel to assist in maintaining the requisite degree of heat. This outfit is. 
required because intravenous infusion is almost a routine procedure at the 
present day. In emergencies a fountain syringe may be used, the infusion 
being made as hot as the hand will bear. The tubing of the irrigating jar 
is fitted with a transfusion cannula (Fig. 1048) or the glass tube of a 
medicine-dropper may be used as a cannula. The operation is preceded by 
the application of a tourniquet to distend the veins. The most conspicuous 
vein should then be chosen, and this, as a rule, is the median basilic. A cuta- 




Fig. 



1045. 



— Colon Irrigation 
Double Catheter. 



DECINORMAL SALINE SOLUTION INJECTIONS. 



931 



neons incision is made of sufficient length to expose about half an inch (1.25 cm.) 
of the vein, which is then isolated and raised from the wound (Fig. 1046). The 
vessel is then tied with fine catgut as low down as possible and a second ligature 
is placed high up, ready to be knotted when desired. Half of the circumfer- 
ence of the vein is now divided with scissors, the incision being just above 
the knotted ligature. The cannula with its stream of running water is now 
inserted as far as possible into the incision, with point directed toward the heart, 
and the second ligature knotted to retain the instrument in place. The knot 
should be a bow, in order that the ligature shall be only temporary. After 
the cannula is removed the same ligature may be used for the purpose of tying 
the central end of the exposed vein. After application of the temporary liga- 
tures the tourniquet should be re- 
moved. Kemp emphasizes the fact 
that a very common mistake of the 
beginner is neglecting to remove the 
tourniquet before proceeding with 
the infusion; under these circum- 
stances the increase in intravenous 
pressure will burst the vein sooner or 
later. 




Fig. 1046. — Infusion of Sal- 
ine Solution into a Vein 
of the Arm. 



Fig. 1047. — Same as Fig. 
1046, but Enlarged. 



Fig. 1048. — Can- 
nula for In- 
travenous In- 
fusion. 



Enteroclysis. — No special apparatus is required, as the single- or double-cur- 
rent irrigation tubes will suffice. Assuming that the solution should have a tem- 
perature in the intestine of at least ioo° F., it should be exhibited one or two 
degrees higher to allow for slight cooling. The dorsal position appears to be the 
best, the hips being slightly elevated. It is well to let the solution escape while 
the tube is being inserted. A number of double-current rectal tubes have been 
devised for the purpose of continuous exhibition of liquids. There are other 
advantages connected with the double system, for the temperature as well as 
the quantity is under control. Continuous irrigation may easily be maintained 
for an hour or more, and the patient may remain entirely passive. A double- 



932 



OBSTETRIC SURGERY. 



current irrigator may be improvised as follows, if the operator has no special 
delivery tube. Two catheters of different caliber should be so fastened 
side by side that the tip of the smaller instrument projects an inch or two 
beyond the larger, and above it, so that the inflow may be on the higher level. 
These catheters should be made to pass through a perineal pad or substitute 
before insertion into the bowel. The escape tube is the larger, for with mucus, 
etc., it must carry away more than enters through its smaller fellow. Dr. 
R. C. Kemp, whose valuable monograph * I have freely consulted in the prepara- 
tion of this section, has devised a double-current irrigator which is the result 
of much study and experience in this department of therapeutics! (Fig. 1045). 
Indications. — In shock, whether post-operative or following hemorrhage, irri- 
gation is so managed that the patient has a pint or a quart of infusion in the bowel 
at any given moment. Continuous irrigation, maintained for a considerable period, 
is^especially indicated in the toxemia of pregnancy. (Page 336.) The hot solution 
(1 io° F. to 120 F.) is advocated in these cases. While enteroclysis has but few in- 
dications in obstetrical practice, by reason of the greater excellence of hypoder- 
moclysis and infusion, it can nevertheless be employed to a considerable extent 
by practitioners who are unfamiliar with the other methods, or who lack the 

necessary apparatus for their perfor- 
mance. 

Hypodermoclysis. — This method 
of. exhibiting the salt solution con- 
sists in its injection into the subcu- 
taneous cellular tissue. Indications: 
Since hypodermoclysis increases the 
quantity of fluid in the vessels, 
thereby making good any deficit, 
as well as acting as a circulatory 
stimulant; and since it promotes 
the action of the emunctories, and 
both dilutes and expels toxic sub- 
stances, it is naturally indicated in 
obstetrical practice in the pregnancy 
kidney and eclampsia, in post-par- 
tum hemorrhage, shock, and sepsis. 
Enteroclysis is a valuable adjuvant 
to hypodermoclysis, either during or 
after the performance of the latter. 
Dangers: The little operation required 
for this purpose is simple, but by no means entirely free from danger. Slough- 
ing has followed hypodermoclysis beneath the female breast. The necessary 
precautions in injecting the saline solution beneath the skin comprise avoidance 
of overdistending the tissues by too much liquid or too great rapidity of flow, 
and manipulation of the apparatus in such a manner that no air is able to enter 
the tissues. ^ Site of Injection: The iliolumbar site (i. e., the space between the 
crest of the ilium and the lower border of the ribs) possesses natural advantages 
as the site of injection. The patient may thereby retain the dorsal position 
and have the free use of all her limbs. Submammary injections are also useful. 
In shock or hemorrhage it may be necessary to give injections in more than 
one locality. Technique: As a general rule, from 4 to 8 ounces constitute a 
single injection in hypodermoclysis. The solution to employ is the ordinary 

*•' Enteroclysis, Hypodermoclysis, and Infusion." 
■fOp. cit., and "Medical Record," July 24, 1897. 




Fig. 1049. — Subcutaneous Infusion of Sa- 
,, line Solution into Both Breasts (Hypo- 
\ dermoclysis). 



ANESTHESIA IN OBSTETRICS. 933 

decinormal formula. The technique of hypodermoclysis is as follows : The appa- 
ratus required is simple, consisting of a fountain syringe and an aspirating 
or hypodermic needle (Fig. 1049). If an ordinary hypodermic needle is used, 
the bag of the fountain syringe must be raised to the height of from 4 to 6 
feet, because of the increased resistance of the fine lumen; and, generally speak- 
ing, the larger the needle, the lower the pressure required. Much time is wasted 
if a hypodermic needle is used. The average height to hang the bag, if a 
medium-sized aspirator is used, is two or three feet, depending on the rapidity 
of the flow. The fountain syringe and its tube, together with the needle used, 
should all be sterilized by boiling, and the bag should contain more water than 
is injected lest air enter the in-flowing stream. The fluid should flow freely 
from the needle as the puncture is made. The same precautions are to be used 
as in any hypodermic injection in regard to the introduction of the needle. 
If more solution is needed, — and as much as a pint may be employed with 
benefit in some cases of hemorrhage, — it should be injected in divided quantities 
into different localities (Fig. 1049). The temperature of the solution should be 
about 105 F. if a large needle is used, but at least five degrees higher if the 
small hypodermic needle is employed, since fully that amount of heat will be 
lost with a fine needle. Local anesthesia may be applied before the puncture, 
if desired. 



III. ANESTHESIA IN OBSTETRICS. 

i. During Labor. — Choice between Chloroform and Ether. — The rela- 
tive advantages of chloroform and ether are very different when it is desired 
to induce analgesia after the beginning of labor. Here two factors contribute 
to increase the safety of chloroform. They are: First, the stimulating effect of 
the labor pains upon cardiac innervation; second, the "physiological anesthesia" 
attendant upon cerebral congestion induced by the bearing-down efforts. The 
first factor helps to prevent chloroform syncope, and the second to diminish 
the amount of chloroform required. It is nevertheless true that the safety 
of chloroform in labor is relative, not absolute, and that fatal cases have been 
recorded. Its prolonged administration — e. g., when commenced early in labor — 
is not only injurious to the mother, but, as recent observations have shown 
is likely to be fatal to the child. Ether is used by a few obstetricians as an 
analgesic during labor. It has been found that most of the objections to its 
use have little force, or have been due to its improper administration, and 
for six years past I have used it almost to the exclusion of chloroform in both 
normal labor and obstetric surgery. 

Indications. — The most common indication for anesthesia is unusual severity 
of the pains. If the labor is long and the pains are abnormally severe, its use 
is justifiable on the ground of humanity and to diminish the shock attendant 
upon severe and prolonged suffering. The administration of the anesthetic, 
however, should be delayed as long as practicable and confined principally 
to the second stage. An anesthetic is frequently useful in aiding the progress 
of labor, especially in the case of nervous and sensitive women who are badly 
affected by the pains, and in cases in which the contractions, while very painful, 
have but little power and in which the uterus does not relax between the pains. 
In cases like the above, in which the reflex influence of the pains delays the 
progress of labor, superficial anesthesia during the pains is frequently very 
useful. Anesthesia in the second stage will often serve to induce timid and 
nervous patients to assist the progress of labor by voluntary efforts. Anesthesia 



934 



OBSTETRIC SURGERY. 



to the surgical degree while the head is passing the vaginal outlet is often of 
the greatest value in preventing perineal laceration, especially in primiparae. 
In ordinary cases the anesthesia is to be used only during the pains, and in 
quantities only sufficient to dull the pains, complete anesthesia being carefully 
avoided. Anesthesia after delivery should be dispensed with unless impera- 
tively indicated. Contraindications: The contraindications to the use of anes- 
thesia during labor are the same as in general surgery, with the important 
modification, however, that the excitement, suffering, and muscular exertion 
which accompany labor without anesthesia may be more dangerous in certain 
morbid conditions—^, g., cardiac disease — than the anesthesia itself. Advan- 
tages: Anesthesia during labor diminishes pain; in certain cases aids in the 
progress of labor; by relaxing the tissues aids dilatation of the cervix; and aids 
materially in the preservation of the perineum. Disadvantages: In some cases 
it diminishes or suspends uterine contractions; produces unpleasant or dan- 
gerous after-effects; and 
predisposes to postpar- 
tum hemorrhages; and 
if excessively used, to 
subinvolution and conse- 
quent sepsis. 

Administration of 
Chloroform. — The pa- 
tient being in the re- 
cumbent position and the 
usual precautions of ex- 
amining heart, lungs, 
and urine, removing false 
teeth, and anointing the 
skin about the mouth 
and nose having been 
observed, at the begin- 
ning of a pain a few 
drops of chloroform are 
dropped upon a towel or 
napkin, held a few inches 
from the nose so as to 
allow a sufficient admix- 
ture of air. This is the "drop" method. An Esmarch inhaler is convenient 
(Fig. 1050). Valuable rules for the administration of chloroform are: (1) Use 
as little chloroform as possible. (2) Use napkin, towel, or Esmarch inhaler 
and the "drop method." (3) Have the chloroform vapor well diluted with air, 
especially at the beginning of anesthesia. (4) At first use only during uterine 
contractions. (5) When an operation is necessary, disease of the heart, lungs, 
or kidneys, or exhaustion attendant upon the third stage, are not contraindica- 
tions to anesthesia. Nevertheless the least dangerous anesthetic or combination, 
such as nitrous oxide and ether or ether and oxygen, should be employed, and 
extreme care exercised in their administration. Valuable danger-signals in 
chloroform narcosis are: (1) Sudden paleness or lividity of the face. (2) Shal- 
low, sighing respiration. (3) Rapid, irregular, intermittent, or failing pulse. 
(4) Sudden dilatation of the pupils. 

Administration of Ether. — If ether is used, the quantity may be some- 
what larger, and an improvised cone, made from a newspaper or a folded towel, 




Fig. 1050.- 



-The Administration of Chloroform with 
an Esmarch's Inhaler. 



ANESTHESIA IN OBSTETRICS. 935 

may be employed. Both in normal labor and obstetric surgery I am accustomed 
to use an Allis inhaler (Fig. 1051 ). I begin its use in the latter half of the second 
stage, often earlier, as early as the end of the first stage; in the last instance, 
however, only during the acme of the pains, and to a very moderate degree 
of anesthesia. 

2. For Obstetric Operations. — Choice Between Chloroform and Ether. — 
The choice of an anesthetic for obstetrical operations will vary with the operator. 
In the case of an operation performed before the beginning of labor, we are 
influenced in our choice by the same conditions which would influence us in 
the performance of any surgical operation. The only exception to the rule is 
in the case of puerperal eclampsia, in which most authorities advise the use 
of chloroform in preference to ether. In Europe and in the southern and 
western portions of this country chloroform is usually preferred, although ether 
is undoubtedly gaining ground, while in the northern and eastern sections of 
this country ether is used in the great majority of cases. In the face of modern 
statistics there can be little doubt that under ordinary circumstances, and 
especially in the hands of any but an expert anesthetist of large experience, 
ether is the safer, and therefore the 
preferable anesthetic. Chloroform 
is undoubtedly the more convenient, 
but, as I have remarked in another 
connection, no question of conveni- 
ence should be allowed to interfere 




with the safety of the patient. The 
ordinary alleged contraindications to 
the use of ether, such, e. g., as pul- 
monary and nephritic complications, 
etc., are discussed in text-books 
upon surgery, to which the student 
is referred. 

3. Anesthesia as an Aid in Diag- 

nncJc Tn drmh+fii1 mcas it ic qottip FiG - 1051— SELF-ADMINISTRATION OF ETHER 

nosis.— In doubtiul cases it is some- WITH \ N Allis i NH aler for Dulling the 

times necessary to insert the hand Intensity of the Pains. 

into the uterus in order to make a 

positive diagnosis. In these cases one should carry the anesthesia to the 

surgical degree, since complete relaxation greatly facilitates the examination. 

The anesthesia, however, should be discontinued as soon as practicable. 

Other Anesthetics. — Chloral is a valuable agent for inducing analgesia during 
labor. Under its influence the severity of the pains is diminished and between 
the pains the patient is drowsy and comfortable. It also helps materially in 
aiding dilatation of the cervix. It is especially useful in the case of nervous 
and sensitive women and in cases in which the severity of the pain is out of 
proportion to the progress of the labor. Chloral may be given in fifteen- 
grain doses repeated at intervals of twenty minutes. Not more than three 
doses should be given, and one or two are usually sufficient. Morphin, either 
by the mouth or hypodermic ally, is sometimes useful, especially when anemia 
or debility renders other agents inadvisable. (See Prolonged Labor, page 629.) 
Antipyrin in large doses has been successfully employed, but in the presence 
of safer methods its use does not seem advisable. The topical application 
of a solution of cocain to the cervix produces a limited degree of anesthesia 
during the stage of dilatation. The objections to its use are the possibility 



936 OBSTETRIC SURGERY. 

of constitutional symptoms, and the danger of sepsis from intravaginal manipu- 
lations. 

Spinal Anesthesia. — Until further reliable confirmation of the safety and 
value of lumbar anesthesia is received, it seems advisable for obstetricians in 
general to refrain from exposing their patients to its dangers. 

Conclusions. — (i) For operations requiring anesthesia to the surgical degree, 
ether, unless contraindicated, is to be preferred, except in cases' of eclampsia. 

(2) In surgical anesthesia during labor in which the operation is begun 
under chloroform, and especially in the case of anemic and exhausted patients, 
ether may advantageously be substituted for the remainder of the operation. 

(3) For dulling the pains of labor, chloroform carefully used, and carried only 
to the extent of primary anesthesia, is both convenient and relatively safe; but 
when this intermittent anesthesia is long continued, it is likely to affect the 
fetus injuriously and is dangerous to the mother, and ether is to be preferred. 

(4) Chloral and morphin, especially the former, are, when indicated, of great 
value. (5) The production of local anesthesia by topical applications to the 
cervix is not to be advised. 



IV. POSTURE IN OBSTETRICS. 

A study of the posture assumed during labor by the women of barbarous 
and semi-civilized races teaches us nothing of practical importance. Custom 
rather than instinct appears to dictate the choice of these obstetric attitudes. 
The women of contiguous tribes may show notable differences in this respect. 
Those who are interested in the subject of labor among primitive people may 
consult the special works of Engelmann and Witkowsky. Instinct may indicate 
the best position for the woman at a given moment, but we have no right to 
assume hastily that this position would be the best for other women or for 
the sex as a whole. Some of the poses adopted by women under these cir- 
cumstances appear to be distinctly contraindicated at the time. Does a woman 
ever instinctively assume the Walcher position when the head is trying to enter 
the brim? However, the postures assumed by the vast majority of women in 
the different stages of labor are such as harmonize with the mechanism of 
labor; thus, when the fetal head is high the patient prefers to stand erect, 
sometimes even leaning a little backward. After the head has passed the brim 
she leans forward, or perhaps kneels to assume the sitting position; while if 
lying down, she draws up her knees and perhaps raises the head and shoulders. 
A rational study of the relation of posture to labor is of the greatest importance 
and leads to most practical results. 

There are but two classes of posture which have a special bearing upon 
midwifery. First, those which alter the shape of the pelvis; second, those in 
which the pelvis is elevated so that it becomes the highest portion of the trunk. 
A knowledge of the former enables the obstetrician to facilitate delivery through 
the resulting diminution of the osseous resistance; while familiarity with the 
latter enables him to retard labor and replace small prolapsed parts, perform 
version, etc. These classes will be considered in detail. 



1. POSTURES WHICH ALTER THE SHAPE OF THE PELVIS. 

Owing to the mobility of the pelvic articulations, certain changes in the 
position of the patient are accompanied by corresponding changes in the dimen- 



POSTURE IN OBSTETRICS. 



937 



sions of the pelvis. Owing to serous infiltration and consequent softening of 
the pubic ligaments, the separation of the bones at the pubic symphysis is 
normally exaggerated during pregnancy, and thus the circumference of the 
pelvic inlet somewhat increased. It is not generally recognized, however, that 
the limited but appreciable movements of which the sacro-iliac joints are capable 
are an important factor in the production of changes in the pelvic dimensions. 
In the erect position or in the horizontal position with extended thighs there 
is a slight backward movement of the sacrum which tends to increase the antero- 
posterior diameter of the inlet. On the contrary, if the thighs are strongly 
flexed and the body is bent forward the upper end of the sacrum is tilted forward 
and its lower end backward, 
the antero-posterior diame- 
ter at the inlet being thus 
diminished while that of the 
outlet is increased. As a 
result of the study of the 
foregoing facts, and t>y imi- 
tating the methods of nature, 
the obstetrician is able to 
produce at will an increase 
of the conjugate diameters 
of either the inlet or the 
outlet of the pelvis. The 
fact is utilized in normal 
labor, as I have already 
noted. It is also, as we 
shall presently see, of great 
value in the conduct of 
operative deliveries. The 
pelvic inclination varies ac- 
cording to the position of 
the woman, and may, of 
course, be abnormal in cases 
of pelvic deformity. This 
variation is dependent upon 
the motion which exists at 
the sacro-iliac joints, the 
pelvic brim swinging a little 
upward and downward ac- 
cording to the position of 
the patient. Separation of 
the knees, by increasing the 
tension of the ilio-femoral ligaments, increases the angle of inclination. The 
normal pelvic inclination in the standing position is from 50 to 60 degrees 
(Fig. 1052). The pelvic inclination in the dorsal position with the legs extended 
is 30 degrees (Fig. 1053); in the dorsal position with the thighs and legs flexed 
and heels close to the buttocks with knees moderately separated it is 40 degrees 
(Fig. 1055); while in the dorsal position with the thighs -strongly flexed upon 
the abdomen and the knees widely separated, namely, the exaggerated lithotomy 
position, the angle is 60 degrees (Fig. 1057). 

1. The Walcher Posture (Fig. 1056). — This is the opposite of the exaggerated 
lithotomy position. The patient is placed on her back in the "cross-bed" 




Fig. 



ent Tract and Degree of Pelvic Inclination 



Pi 



938 



OBSTETRIC SURGERY. 



position, or preferably on a table, in such a manner that the sacrum rests upon 
the edge of the table, the thighs and legs being allowed to hang downward 
by their own weight. In this position the pelvic inclination is increased and 
the conjugate diameter of the pelvic inlet slightly increased. The vaginal outlet 
is drawn so far down that the angle formed by the long axis of the uterus with 
that of the vagina is diminished, and the ui ero- vaginal canal becomes less 
curved and approaches a straight line (Fig. 1056). Manual manipulations are 
thus much facilitated. According to Walcher,* the conjugate is increased from 
0.33 to 0.5 inch (8.5 to 13 mm.). Fothergill estimates the average difference 
between the conjugate in the lithotomy position and the same measurement 
in the Walcher position as 0.36 inch (9.3 mm.). At the New York Maternity, 
in 1898, I measured several series of cases from among the waiting women 
with a Farabeuf pelvimeter (Fig. 219) in the lithotomy position with moderate 
flexion of the thighs, and then in the hanging Walcher posture. A gain in the 
true conjugate with the latter position was readily demonstrated. This increase 




Fig. 1053. — Dorsal Posture with Extended Thighs, showing the Parturient Tract 
and the Degree of Pelvic Inclination. — (From a photograph taken at the Emer- 
gency Hospital.) 



in the true conjugate varied from one-fourth to one-half an inch (0.635 cm - 1° I - 2 7 
cm. ) , averaging higher in multigravidas than in primigravida?. The mechanism of 
the Walcher position *is dependent upon the motion of the sacro-iliac synchron- 
drosis, and is explained as follows : The weight of the limbs hanging from the edge 
of the table causes the ilia to rotate forward and downward around the trans- 
verse axis of the joint. Thus the angle made by the plane of the brim with the 
horizon is increased, and consequently the symphysis pubis is brought a little 
forward and downward and a little further from the sacrum. (See Fig. 1048.) 
It should not be forgotten that the Walcher position may be utilized in breech 
presentations as well as in vertex. f 

* "Ctbl. f. Gyn.," 1889, S. 892. 

t The Walcher position was described and illustrated in Italy many years ago. Its 
use, however, was purely empirical. It was supposed to make the child more movable 
and to be useful in the delivery of fat patients. It remained for Walcher to demonstrate 
the mechanism involved and thus to place the matter upon a scientific basis. 



POSTURE IN OBSTETRICS. 



939 



2. Exaggerated Lithotomy Posture (Fig. 1057).— Dorsal postures are subdi- 
vided in accordance with the position of the legs. If the latter are horizontal, 
the angle of the inlet is 30 degrees (Fig. 1053). If the thighs and legs are flexed, 
the feet resting on the table, the angle increases to 40 degrees (Fig. 1055); and 
if the degree of flexion is extreme, the patient being in the exaggerated lithotomy 
posture, the angle is 60 degrees (Figs. 1057, 1058). With increase in the size 
of the angle of inclination, the fundus tilts backward more and more, while the 
lower portion of the birth canal is correspondingly elevated. The angle of the 
two portions of the birth tract, uterine and vaginal, appears to undergo but 
little change during flexion of the limbs. The dorsal position with extreme 
flexion of the limbs is indicated for slight degrees of obstruction at the pelvic 
outlet and for all operations after the head has passed the brim. 



2. POSTURES WHICH ELEVATE THE PELVIS. 

These are four, in two of which the woman is prone, knee-chest and exag- 
gerated lateral prone, in the others, supine, Trendelenburg and Trendelenburg- 




Fig. 1054.— Dorsal Posture with Elevation - of the Thorax, showing the Par- 
turient Tract and the Degree of Pelvic Inclination. — (From a photograph 
taken at the Emergency Hospital.) 



Walcher. The general result of these high pelvic positions is naturally one of 
gravitation. The pelvic viscera sink toward the diaphragm, and the result from 
the obstetrical standpoint is twofold. First, the fetus sinks away from the cer- 
vix, with the result in the first stage that the uterine contractions are diminished 
in force and frequency. The second consequence of the high pelvic postures 
is that the pelvis becomes more ample, so that the entire hand may readily be 
introduced. The combined results of elevation of the pelvis give the obstetrician 
a high degree of control over certain phenomena of normal and pathological 
labor. He can delay rupture of the bag of waters, antagonize over-strong 
pains, facilitate certain manceuvers which are best done with the entire hand 
in the vagina, and prevent the redescent of the small parts of the fetus. 



940 



OBSTETRIC SURGERY. 



i. Knee-chest Posture (Fig. 1059). — Sims,* in his original description of this 
position, states that the woman should first kneel and then bend the body 
forward till the head reaches the level of the table, where it should rest upon 
the two hands. The weight is supported by the left parietal bone, the elbows 
being thrown out widely at the sides. The knees should be 8 or 10 inches 
(20.32 or 25.4 cm.) apart and the thighs should form nearly a right angle with 
the table. The woman thus supported should remain perfectly quiet, only the 
necessary muscles being contracted. After a few moments' interval the abdomi- 
nal and pelvic viscera gravitate toward the epigastrium. It is apparent that 
in the knee-elbow position the weight in front is supported upon the forearms, 
while a knee-chest position is impossible unless pillows are placed beneath 
the chest. 

2. Latero-prone Position with Elevated Hips (Figs. 1060 and 1061). — This is 




Fig. 1055. — Dorsal Posture with Moderate Flexion of the Thighs, showing the 
Parturient Tract and the Degree of Pelvic Inclination. Note the slight up- 
ward rotation of the symphysis and enlargement of the pelvic outlet. — (From a pho- 
tograph taken at the Emergency Hospital.) 



perhaps superior, in filling certain indications, to both the knee-chest and 
Trendelenburg positions. It is far more acceptable to the patient, who can 
assume it for an indefinite period. She may lie at first in the ordinary lateral 
decubitus and then have one side of the pelvis gradually elevated by slipping 
cushions under the hip. Other cushions are placed beneath the head and 
chest, as these structures support the weight in front. The woman rests upon 
the side of the head, the entire breast, and the side of one knee. The elevation 
of the buttocks appears to equal, for all practical purposes, that produced by 
the Trendelenburg and knee-chest positions. Obstetricians of a bygone age 
(Deventer, Ritgen) counsel the employment of this attitude, although they 
seem to regard it as a makeshift for the more efficacious but hardly en- 
durable knee-chest posture. It is probable that they did not attempt to 
* "Clinical Notes on Uterine Surgery." 



POSTURE IN OBSTETRICS. 



941 



elevate the pelvis beyond a certain limited height. The superiority of the 
exaggerated latero-prone position lies in its adaptability and modesty as com- 
pared with the knee-chest position. For many years I have used it in my 
practice to the exclusion of the uncomfortable knee-chest posture. 

Indications for the Knee-chest and Exaggerated Lateral Prone Postures. — These 
twofpostures are of service during pregnancy, labor, and the puerperium. In 
pregnancy they are useful for external ballottement and also for exploring the 
sides of the pelvis. Generally speaking, examinations in these positions give 
results which supplement those obtained by exploration in the dorsal attitude. 
From a therapeutic standpoint the postures are of some use in procuring tem- 
porary relief from all conditions which arise from pressure of the gravid uterus 




Fig. 1056. — Walcher Posture, showing the Parturient Tract and the Degree 
of Pelvic Inclination. Note the downward rotation of the symphysis and the 
enlargement of the pelvic inlet. — (From a photograph taken at the Emergency Hospital.) 



on the tissues beneath (hemorrhoids, constipation, vesical trouble, obstruction 
of ureters, etc.). Late in pregnancy the woman may systematically assume 
these positions at stated intervals. Early in the course of gestation it is some- 
times possible to relieve the vomiting of pregnancy by this means. For one 
complication of pregnancy, retrodisplacement of the uterus, this postural treat- 
ment is indispensable, although manual reposition is used as an accessory 
measure. (See page 311.) In labor the assumption of the knee-chest or lateral 
prone position arrests contractions for the time being. In normal labor there 
is no very "strong indication for the assumption of these positions. They directly 
antagonize the action of gravity in promoting labor, and are thus distinctly 
contraindicated in the first stage. In theory they might be indicated when 
precipitate labor is threatened, and in attempts to defer rupture of the bag 



942 



OBSTETRIC SURGERY. 



of waters. There is no indication for forceps delivery in these postures, but 
in version they present numerous advantages: (i) The uterus sags away from 
the pelvis, giving the operator more room to introduce his hand; (2) labor pains 
are arrested for the time being, and (3) there is a natural tendency on the part 
of the knee-chest position to favor the rectification of the malposition for which 
version is required. These postures are most valuable in connection with pro- 
lapse of the funis, yet in this manual replacement must generally be employed 
as an adjunct. In 1882 Galbraith brought about the unlocking of twins by 
causing the mother to assume the knee-chest posture. In theory, at least, the 
latter should favor the reposition of an inverted uterus. 

Of the hanging dorsal or Trendelenburg, and the arched dorsal or Trendelen- 
burg- Walcher positions, the latter is but little known, having been but recentlv 
revived from mediaeval obscurity by Dr. R. L. Dickinson. The pelvic elevation 




Fig. 1057. — Dorsal Posture with Extreme Flexion of the Thighs, showing the 
Parturient Tract and the Degree of Pelvic Inclination. Exaggerated 
Lithotomy Position. Note the extreme upward rotation of the symphysis and the 
enlargement of the pelvic outlet, and diminution of the pelvic inlet. — (From a photo- 
graph taken at the Emergency Hospital.) 



is very slight in the latter, and it might perhaps be better described as a hybrid 
posture in which the size and height of the pelvis are simultaneously affected. 
Each position is described in detail. 

3. Trendelenburg Posture (Fig. 1062).— While this posture appears to be a 
lineal descendant of an old method of applying taxis in hernia, its use has become 
general only of late years, so that the knee-chest position is very much its 
senior in obstetric practice. A woman in the Trendelenburg position lies upon 
her back with her head and arms flat upon the operating table while the rest 
of her person is elevated to an angle of 45 degrees or less, except the legs, which 
hang over the foot of an inclined plane. The weight of the body is supported 
by thehead and knees (Fig. 1062). If the angle of elevation attains a certain 
size, it is necessary to strap the legs. This posture may be improvised in various 



POSTURE IN OBSTETRICS. 



943 



ways: thus, an incline may be formed from an inverted chair and several pillows, 
or the woman may rest, head down, upon the back of a strong attendant with her 
knee hollows upon his shoulders and her legs held in his hands. This was the 
earliest application of the method. The Trendelenburg position is used extensively 
in the laparotomies incidental to obstetrical practice, as in ectopic pregnancy. 
Aside from this, it has been proposed as a substitute in certain cases for the knee- 
chest position. Its advantages over the latter are that it is more natural and 
modest, andean be endured indefinitely, thereby antagonizing a further tendency 
to prolapse of the small parts. It does not conflict with the administration of 
anesthesia. Abrahams * has especially recommended the Trendelenburg posi- 
tion in prolapse of the funis. He cites seven cases in which the children were 
born alive, although the infant mortality is usually given as from 40 to 50 
per cent. He advises placing the woman at once in the position in question, 
after which the entire hand is passed into the vagina. The chances are that 
the cord has already 
slipped back, but the 
operator should wait for 
the next pain before 
withdrawing his hand, 
lest the cord be expelled 
again. If the presenting 
part is wedged into the 
inlet, and perhaps com- 
pressing the cord, it 
should at once be pushed 
up. If the pains are 
very strong, the patient 
may be left in the ex- 
treme Trendelenburg pos- 
ture for a quarter of an 
hour; otherwise the angle 
of inclination should be 
reduced one-half. 

4. Walcher - Trendel- 
enburg Posture (Fig. 
1063). — In the Walcher 
position as usually as- 
sumed, the direction of 
the axis of the utero- 
vaginal canal is almost 

perpendicular, and traction with the hand or forceps must be directly down- 
ward. For this reason a combination of the Walcher position with the well- 
known Trendelenburg is advised. f In this way the advantages of the former 
position are realized while the vulva is at such a height that traction can con- 
veniently be made. The axis of the utero-vaginal canal is horizontal and 
manipulations are thus facilitated. A satisfactory table for this position may 
be improvised by means of an ordinary inverted chair and a mattress. 

Conclusions. — From the foregoing the following conclusions may be deduced: 
(1) When the head is arrested at the pelvic brim, either the Walcher or the 
Walcher-Trendelenburg position is worthy of trial. (2) For all operative cases 




i 



Fig. ios8. — Exaggerated Lithotomy Posture. 



* "Phila. Med. Jour.," 1898. 

f Dickinson: "American Journal of Obstetrics," Dec , 1898 p 791. 



944 



OBSTETRIC SURGERY. 



in which the greatest circumference of the head has passed the brim, the ex- 
aggerated lithotomy position is to be preferred. 

Posture as an Aid to Childbirth. — The principal conditions aided by posture 
are sterility, which has often been overcome by varying the posture of the 
woman during coitus. Thus, in a case of rachitic deformity of the pelvis the 
woman became pregnant after prolonged infertility as a result of copulation 
in the prone position. Intercourse in some upright posture militates against 
conception because the semen drains away; conversely, coitus with the woman 
imthe knee-chest posture has caused impregnation, for the semen is then retained 
in the vagina. In retroversion of the pregnant uterus the patient should be 




Fig. 1059. — Knee-chest Posture, showing the Parturient Tract and the Degree 
of Pelvic Inclination. — (From a photograph taken at the Emergency Hospital.) 



placed in the knee-elbow or the exaggerated latero-prone position, in order 
that reposition of the uterus may be attempted. In over-strong pains, to prevent 
precipitate labor the patient should be placed upon her side and forbidden 
to bear down. In labor in contracted pelvis, with slight disproportion between 
the head and inlet, Walcher's position should be assumed during engagement 
in the inlet. If a similar degree of contraction exists at the outlet, the exag- 
gerated lithotomy position should be assumed. In the first stage of labor posture 
is generally left to the decision of the parturient. She may be seated or may 
walk about. An upright position is held to be of advantage because the weight 
of the fetus may stimulate the cervix to dilate. However, when dilatation is 



POSTURE IN OBSTETRICS. 



945 



nearly complete there is some danger of precipitate expulsion, with possible 
rupture of the cord or injury to the child. It has been suggested as a com- 
promise that the woman should squat or kneel during the latter part of the 




Fig. 1060. — Exaggerated Lateral Prone Posture. Anterior View. — (From a photo- 
graph taken at the Emergency Hospital.) 

first stage, for she thereby retains the benefit of the upright position without 
the risks just enumerated. In the second stage of labor the natural tendency 
during the expulsion period is toward the assumption of the dorsal position. 
It has been ascertained that a reclining attitude facilitates the first half ; of 




V 



Fig. 1061. — Exaggerated Lateral Prone Posture. Posterior View. — {From a 
photograph taken at the Emergency Hospital.) 



the second stage, while during the second half the woman should turn on that 
side toward which the fetal back presents, with her legs strongly flexed. This 
position is believed to favor perfect flexion of the child's head. It is used 
60 



946 



OBSTETRIC SURGERY. 



almost universally in Great Britain throughout the second stage. While conduc- 
ing to modesty, it also lessens the intensity of the expulsive forces during perineal 
dilatation by bringing gravity into play. In the third stage of labor the woman 
should lie flat on her back with the head low. In occipito-posterior positions 
before labor has set in, the woman should assume the knee-chest or latero-prone 
position with elevated hips in the hope that the head will engage in the natural 
way. After labor is under way she should assume the latero-prone position 
on the side toward which the fetal back is directed. In mento-posterior positions 
the patient should be placed on the same side as that toward which the fetal ab- 
domen is turned. This posture favors the desired extension and anterior rotation 
of the chin. With prolapse of an arm, after the head has been pushed up, the 
uterine obliquity usually present is corrected by having the patient lie on the side 
opposite to $hat "to which the fundus inclines. The head should now be able to 








Fig. 1062.— Trendelenburg Posture, showing the Parturient Tract and the De- 
gree of Pelvic Inclination.— (From a photograph taken at the Emergency Hospital.) 



engage without the arm. With presentation and prolapse of the cord our resource 
is often posture. The patient should be placed in the knee-elbow or exaggerated 
semi-prone posture for ten minutes. The head then falls away from the os 
and sinks into the cavity of the uterus. Actual prolapse of the cord re- 
quires the same postural treatment. With short cord the mother may assume a 
squatting or kneeling posture (page 614).* In heart failure an asystolic woman 
can often be safely delivered in a high reclining attitude and afterward may regain 
some compensation (Fig. 1054). It is held that this position aids the failing 
heart and respiration by removing some of the pressure from the diaphragm. 
In post-partum hemorrhage the patient should be flat on her back without pillows 
and the foot of the bed elevated. This posture is indicated also in ante-partum 
and mtra-partum hemorrhages. In forceps delivery the patient is usually placed 
m the lithotomy position. In England she lies in the ordinary obstetrical 
* Brickner: "Am. Jour. Med. Sciences," Nov., 1S99. 



VAGINAL EXAMINATION. 



947 



position, upon the left side. The English and American methods can be com- 
bined by applying the blades in the former and extracting in the latter position. 
In very difficult extraction the Walcher position may be employed until the 
head has passed the inlet, after which the lithotomy position is assumed. In 
version the woman is placed in the Trendelenburg, Walcher, Trendelenburg- 
Walcher or exaggerated lithotomy position according to the stages and difficulties 
of the operation. In dorso-posterior positions one may employ the latero-prone 
position, the woman lying on the side at which is the fetal pole which is to be 
brought down. In case the presenting part is firmly engaged in the inlet, the 






Y 



■*■ 



y 



M? 




Pig. 1063. — Trendelenburg-Walcher Posture, showing the Parturient Tract and 
the Degree of Pelvic Inclination. Note the downward rotation of the sym- 
physis and the enlargement of the pelvic inlet. — {From a photograph taken at the Emer- 
gency Hospital.) 

laiee-elbow position may be used, although I have found the exaggerated latero- 
prone or Trendelenburg posture to answer better. In the puerperium, for the 
first two or three days the dorsal posture is advisable (page 754). After the 
third day the patient's time should be equally divided between the dorsal, two 
lateral, and if possible the abdominal posture (flat on belly) (page 754). Drain- 
age is promoted by an early propping up of the shoulders. 



V. VAGINAL EXAMINATION, 

See Asepsis in Obstetrics, page 152. 



-1 



948 



OBSTETRIC SURGERY. 



VI. DIGITAL EXPLORATION OF THE UTERUS. 

This procedure is often necessary in the diagnosis of incomplete abortion 
and septic conditions, and is performed as follows: The patient is placed in the 
lithotomy position, the operator's hands and arms and the vulva are carefully 
disinfected, and the vagina is irrigated. Two fingers of the right hand are then 
introduced into the vagina and passed through the cervix, the left hand mean- 




Fig. 1064. — Digital Exploration of the Uterus. 



while being placed upon the fundus and the uterus being pressed downward 
and backward into the axis of the bony pelvis (Fig. 1064). In this way the 
uterus may be pressed over the examining fingers like a glove. The anterior, 
posterior, and lateral walls of the uterus are then to be systematically palpated, 
especial attention being paid to the cornua, where retained decidua, chorion, 
or placenta is apt to escape notice (Fig. 1064). The condition of the uterine 
walls is thus appreciated and the presence or absence of placenta or membranes 
noted. In some cases it may be necessary to introduce the entire hand into 
the uterus. This can be done only when the patient has been recently delivered 
and the cavity is of sufficient size. If the patient is unusually nervous or sensi- 
tive, primary anesthesia will first be necessary. 



VULVAL DOUCHE— VAGINAL IRRIGATION. 



949 



VII. VULVAL DOUCHE. 

It is often important that the vulva should be flushed out thoroughly in 
its inner aspect and not merely washed on the outside, as is the ordinary custom. 
The inside of the vulva, in marked 
contrast with the vagina, is the habitat 
of many germs, and in certain cases 
infection may be due to micro-organisms 
from the vulva carried into the birth 
tract on the exploring finger. The vulval 
douche is therefore intended to cleanse 
the inner aspect of the external genitals. 
The woman should lie on her back upon 
a douche pan or a Kelly pad with limbs 
somewhat abducted (Fig. 1058). The 
labia majora are held wide apart by the 
fingers (Fig. 1069), while by the aid 
of an ordinary irrigation apparatus a 
stream of water is directed through a 
glass nozzle upon the labia minora, 
clitoris, vestibule, and other parts com- 
prising the vulva. The cleansing can 
also be accomplished after wide open- 
ing of the vulva with pledgets of 
absorbent cotton first dipped in a soap solution, then in sterile water, and 
finally in an antiseptic, such as a lysol or sublimate solution. To avoid rectal 
contamination, the sponging should always be from above downward. 




g 



Fig. 1065. — The Vulval Douche. 



VIII. VAGINAL IRRIGATION. 

In this, as in all other obstetric procedures, every care should be taken to 
prevent the introduction of infection. The vulva and adjacent regions and the 
hands of the physician should be cleansed as before a vaginal examination. 
(See Asepsis in Obstetrics, page 153.) The patient should be in the dorsal 
position; a glass or metal tube which can be sterilized by boiling is to be pre- 
ferred (Fig. 1067). The intrauterine tube may be used, but a straight tube 
is less likely to enter the cervix or to carry fluid into the uterine cavity. In 
all cases, as in vaginal and uterine manipulations, the vulval canal should first 
be obliterated with the free hand before the introduction of the irrigating 
tube (Fig. 1066). Special attention is to be directed to the posterior cul-de-sac, 
where there is apt to be an accumulation of stagnant secretions. Special care 
is to be taken also that the tube does not enter the cervix and that infectious 
secretions are not washed into the uterus. If necessary, a finger in the vagina 
should be employed to make sure that the uterine cavity is not invaded. A 
common practice in recent years has been tightly to close the vaginal outlet 
about the irrigating tube, in order to increase the intravaginal pressure, balloon 
the walls, and secure a more thorough cleansing. This in the presence of a 
puerperal uterus must be employed with caution, and never without a firm 



1 



950 OBSTETRIC SURGERY. 

grasp of the fundus, and only with moderate increase of intravaginal pressure. 
A fountain syringe is to be preferred for vaginal as for intrauterine injections. 
The temperature of the solution should be from 105 to no° F. There is no 
advantage in a high degree of heat unless hemorrhage exists. The resorptive 
power of the vagina soon after delivery 
is greater than has generally been sup- 
posed. Stronger sublimate solutions than 
1 : 5000 should not be used. For the 




\ 





Fig. 1066. — The Vaginal Douche. 



Fig. 1067. — Blunt Vaginal Douche 
Tube. 



various solutions to be used in vaginal as well as intrauterine injections, see 
Treatment of Puerperal Infection (page 819). Valuable ones are, 1 : 5000 
sublimate; 2 per cent, carbolic acid; 0.5 per cent, lysol or creolin; decinormal 
saline solution, and plain sterile water. 



IX. INTRAUTERINE IRRIGATION. 

An intrauterine injection is by no means an indifferent procedure, and 
should be regarded as an operation — one to be performed with scrupulous 
care and attention to detail. The following are the sources of danger. Shock 
from uterine distention or from too hot or too cold solutions; poisoning, e. g., 
by bichloride of mercury or carbolic acid ; abrasions of the soft parts resulting 
in new foci of infection; dislodgment of clots from the puerperal venous 



INTRAUTERINE IRRIGATION. 



951 



sinuses which may enter the general circulation, and entrance of fluid into 
the Fallopian tubes and peritoneal cavity. 

The intrauterine douche tube should be of glass or metal, that it may be 
sterilized by boiling, should be of medium caliber, and have a suitable curve 
(Fig. 1069). Tubes of tin, the shape of which can be altered at will, are con- 
venient, and metal male catheters may be used in an emergency. The tube 
should be perforated at the sides and there should be no opening at the end. 
The current of fluid should be continuous, not interrupted; a fountain syringe 





- 




*S 



Fig. 1068. — Intrauterine Irrigation. The upper illustration shows a faulty method. 

Note the firm grasp of the fundus. 



is to be preferred, and every care should be taken to prevent the entrance 
of air. The douche bag should be held at such a height that the current is 
sufficient but not strong, two or three feet above the patient's pelvis being 
usually the proper height. The quantity of fluid may vary with the indications, 
less than one quart being rarely used. Solutions: Within the uterus we irrigate 
with plain sterile water or sterile decinormal saline solution; 0.5 per cent, of 
creolin or lysol, 50 per cent, alcohol, and sublimate solution in the strength 
of 1 : 10,000, which last should be followed by a second irrigation of plain 



952 



OBSTETRIC SURGERY. 



sterile water. Administration: The patient should be in the dorsal position, 
and, when practicable, in the lithotomy position. As stated elsewhere, a 
recently delivered patient should never be placed in the Sims position on 
account of the danger of the entrance of air into the 
uterine sinuses. It is rarely necessary, nor is it advis- 
able, to introduce the finger into the vagina as a guide 
to the cervix. The external genitals and hand having 
been cleansed, the physician sits or stands at the side 
of the bed or in front of the patient, and with the 
fingers of the free hand obliterates the vulval canal 
by placing the outer border of the thumb upon the 
inner aspect of one labium and the first and second 
fingers upon the inner surface of the opposite labium, 
and widely separates them (Fig. 1066). The irrigating 
tube is then passed directly into the vagina and first 
a thorough vaginal irrigation is administered, during 
which the free hand firmly grasps the fundus. The 
fundus is then pushed backward, and by the sense of 
touch the irrigating tube is passed on into the uterus, 
always remembering to keep a firm grasp upon the 
fundus to prevent dilatation of the uterus and opening 
of the sinuses (Fig. 1068). 

The tube should be carried to the fundus, and care 
should be taken that the soft tissues of the uterine wall 
are not injured by rough or careless movements. Some 
instruments — e. g., the Fritsch-Bozeman intrauterine 
catheter, and the author's irrigating tube — provide for 
the return of the fluid, but this may be promoted, if 
necessary, whatever instrument is used, by gentle pres- 
sure with the instrument against the anterior lip of the 
cervix. During the entire process the patient should 
be carefully observed, and at the first evidence of 
pallor or twitching of the facial muscles, or of pain 
or constitutional disturbance, the injection should be 
stopped. If there is uterine hemorrhage, showing the 
dislodgment of a clot, the injection should be suspended. Retained fluid is 
best expressed by compression of the fundus. 



f P!dH 


W'mKfl 

B94 I ,'»9^H 




\ 




i 


1 : 




I 


SIDE 




'\ 


VIEW. 


f 




FRONT 


* 





view. | ;l 


1 


I 


CROSS ™ 


SECTIONQJ) 



Fig. 1069. — Author's 
Return Flow Glass 
Vaginal and Uter- 
ine Irrigating 
Tubes. 



X. THE VAGINAL TAMPON. 

This is best applied with the patient in the Sims position and the perineum 
drawn back by a speculum. The dorsal posture and a perineal retractor can 
also be used. The external genitals should be disinfected and the vagina care- 
fully swabbed out with a piece of gauze soaked in an antiseptic solution. The 
tampon should preferably be of gauze, but in the absence of this material may 
be of absorbent cotton or lamp-wick, soaked in an antiseptic solution. The use 
of plain sterile gauze is not advisable owing to the danger of decomposition 
of retained secretions. In order to be efficient, the tamponing should be done 
carefully and thoroughly. The vaginal fornices should first be packed, and as 
the speculum is gradually withdrawn the rest of the vagina is filled (Fig. 1070). 
The tampon is held in position by a rather tight-fitting T-bandage (Fig. 278). 



THE UTERINE TAMPON. 953 

It should not remain in place more than twelve hours. At the end of this 




Fig. 1070. — The Vaginal Tampon. 

time it should be removed, and a second tampon introduced and left for another 
twelve hours. 



XI. THE UTERINE TAMPON. 

As stated elsewhere, the intrauterine tampon is used for the purpose of 
controlling hemorrhage and occasionally in the treatment of septic conditions. 
The method of procedure is as follows: The patient being in the lithotomy 
posture, the vulva and adjacent regions are cleansed and the vagina is irrigated; 
the perineum is depressed with an ordinary retractor; the anterior and posterior 
cervical lips are seized with volsella forceps or tenacula and the uterus is 
drawn down and held by an assistant (Figs. 107 1 and 1072). A long strip of 
gauze is now passed into the uterine cavity by means of a long, blunt-pointed 
dressing forceps. The strips should be a hand's-breadth in width and folded, 
and about three or four yards in length, for the full-term puerperal uterus, and 
correspondingly smaller for the earlier months. Unmedicated sterile gauze is 
to be preferred. Every precaution should be taken to prevent infection, and 
the gauze should be carried by the dressing forceps directly from its special 
receptacle into the uterus without touching any foreign body which might con- 
taminate it. During the entire operation the dressing forceps holding the gauze 
should be guided and controlled by the external hand grasping the fundus, 
which makes sure that the gauze has reached the fundus. The gauze is gradu- 
ally introduced, the object being completely to fill the uterine cavity from 



954 



OBSTETRIC SURGERY. 



above downward (Figs. 107 1 and 1072). A loose packing is left in the vagina. 
If, however, in cases of hemorrhage, the bleeding conies from the lower 
uterine segment, as in some cases 
of placenta praevia or cervical lacera- 
tion, the vaginal packing should be 
tight. 





S&S 



% 



Fig. 107 i. — Method of Packing the 
Puerperal Uterus. — (From a photo- 
graph.) 



Fig. 



1072. — Method of Packing the 
Puerperal Uterus. 



In some cases the uterus may be pressed down so far that it is not necessary 
to draw it down by means of instruments, and if the latter are lacking, the 

gauze may usually be introduced 
by means of the hand being 
passed into the uterine cavity. 
If sterile gauze is not at hand, 
clean linen or other material 
which has been boiled and 
soaked in a disinfectant solution 
may be substituted in the case 
of grave emergency. A most 
convenient method for uterine 
as well as vaginal tamponade 
will be found in the use of a 
mechanical surgical dressing- 
packer.* I have for several 
years in hospital and private 
work used two sizes, No. 3, 
outside diameter -^ inch, for 
the puerperal uterus of the early months, and for packing the lower uterine 
segment to induce abortion; and No. 4, outside diameter f inch, for packing 

* Darmack patent. 




Fig. 



1073. — Packing the Puerperal 
with a Metal Gauze-packer. 



Uterus 



ARTIFICIAL RUPTURE OF MEMBRANES. 



955 



the larger puerperal uterus and the lower segment to induce premature labor. 
No. 3 carries gauze from | inch to ij inches wide; No. 4, from 4 inches to 
6 inches (see Figs. 1073 and 1079). To use the instrument, 
the lithotomy position, with the perineum retracted and the 
cervix held with volsella forceps, is to be preferred. 

Hemorrhage coming on in from half an hour to an hour 
after the insertion of the uterine tampon indicates that 
blood is being squeezed from the gauze by uterine contrac- 
tions. In such a case further tamponing is not indicated, 
but, rather, the removal of the gauze. The tampon should 
not be allowed to remain in situ for more than twelve 
hours, and its removal should usually be followed by uterine 
and vaginal irrigation with some non-toxic solution. 



XII. PASSING THE CATHETER. 

The patient is placed in the dorsal position with thighs 
rotated outward. The labia are held apart by the fingers 
of one hand (Fig. 1066), while with a pledget of cotton 
dipped in an antiseptic solution, such as 1 per cent, lysol, 
the vestibule is carefully wiped from above downward. A 
glass catheter (Fig. 1074), previously boiled, is then intro- 
duced into the meatus and the water drawn. Since anti- 
sepsis and asepsis have been elaborated, it is considered 
wiser to catheterize the woman by the aid of direct inspec- 
tion than by the mere sense of touch. For special direc- 
tions for using the catheter, see Affections of the Bladder in 
Pregnancy (page 360), Labor (page 530), and the Puer- Fig. 1074.— Glass 
perium (pages 765 to 767). Catheter. 



(B) OPERATIONS PREPARATORY TO DELIVERY. 
I. ARTIFICIAL RUPTURE OF MEMBRANES. 

This procedure is of such simplicity that it hardly deserves to be ranked 
as an operation. Indications : When the cervix is fully dilated and the bag of 
waters is still intact, the obstetrician may interfere. The amniotic fluid has 
completely discharged its function of aiding the first stage of labor and would 
constitute an impediment in the period of expulsion. In twin labors after the 
birth of the first child, the os being well open, the bag of waters of the second 
twin will be of no further service, and should be ruptured after a short interval 
of expectancy. When the bag of waters persists throughout labor, the mem- 
branes should be ruptured immediately lest the newly born child be asphyxiated. 
Artificial opening of the membranes is sometimes indicated with the os not 
fully dilated. Thus the bag of waters may prolapse through a partially open os, 
and even descend to the level of the vulva. This has been termed the "sausage- 
shaped" protrusion of the bag of waters, and sometimes stands in causal relation 
to premature detachment of the placenta. On this account alone it may be 
necessary to rupture the membranes. Again, if there are adhesions between 



956 



OBSTETRIC SURGERY. 



the cervix and membranes which cannot be separated by the finger, artificial 
rupture may be indicated. In placenta prasvia lateralis the indication is for 
early rupture of the membranes in advance of dilatation, in order that the 

fetal head may descend and compress the lower seg- 
ment (page 236). In premature detachment of a 
normally seated placenta the indication is the same 
(page 242). Finally, most cases of operative inter- 
vention require rupture of the membranes. Tech- 
nique : The fingers should pinch up a fold of the 
membranes and tear it apart. If the membranes are 
very firm or tense, the rupture must be produced by 
scissors or dressing forceps, or any sterile pointed 
instrument. I am accustomed to cut a notch on the 
edge of the nail of the index-finger, to produce a 
saw-tooth (Fig. 1075). By one or two sawing motions 
with the nail the membranes are readily cut through. 
The rough edge of the finger-nail can then be removed 
to prevent the lodgment of foreign substances. 




Fig. 1075. — Notched Fin- 
ger-nail for Artificial 
Rupture of the Mem- 
branes. 



II. INDUCTION OF ABORTION AND PRE- 
MATURE LABOR. 



Definitions. — The terms abortion and premature 
labor are applied with considerable looseness by 
various writers to express the termination of preg- 
nancy at various periods before term. It seems logical, however, to draw the line 
at the approximate period of pregnancy at which the child is fitted for extra- 
uterine existence, i. e., the seventh month, and to divide abortions into early and 
late. An early abortion is one occurring within the first twelve weeks. Up to 
this time the ovum usually comes away in nearly a complete condition, while 
after the third month three stages of labor may be distinguished. It is advisable 
to make this distinction between early and late abortions, since the methods 
of treatment for each period are different. Induction of abortion is performed 
entirely in the interest of the mother; induction of premature labor may be done 
in the interest of either or both. 

Importance. — For the conscientious physician the interruption of pregnancy 
naturally involves great responsibility, but when it is the only method of saving 
the life of the mother, or when without it her life is placed in imminent danger, 
it is usually regarded as not only justifiable but imperative. If possible, it 
should always be preceded by a consultation, which may not only prevent 
the unnecessary sacrifice of fetal life but protect the reputation of the physi- 
cian. 

Indications for the Induction of Abortion. — These may be summed up as all 
•conditions which render the continuance of pregnancy fatal to the mother. 
They may be divided into general and local maternal indications, and fetal 
indications. The chief general maternal indications are hyperemesis of pregnancy, 
•eclampsia which does not yield to medicinal treatment, severe nephritis, ad- 
vanced pulmonary or cardiac disease, insanity, and chorea. Local maternal 
indications include serious irreducible uterine displacements, such as anteflexion, 
prolapse, or hernia, or incarceration in the pelvis of a retroflexed uterus ; extreme 



INDUCTION OF ABORTION AND PREMATURE LABOR. 



957 



pelvic contraction, indicated by a true conjugate of two and a half 
inches or less; impassable obstruction of the genital canal by tumors, 
either benign or malignant, cicatrices of the cervix and vagina, etc.; 
when laparotomy is deemed inadvisable or is refused; hemorrhage 
from placenta prsevia or persistent bleeding from partial separation of 
a normally implanted placenta. Fetal causes are cystic disease of 
the chorion, acute hydramnios, death of the fetus. In the latter 
case the artificial interruption of pregnancy may not be indicated 
or even advisable unless called for by maternal symptoms; e. g., 
hemorrhage, sepsis. 

Indications for the Induction of Premature Labor. — Many indi- 
cations have already been mentioned for the induction of abortion. 
Among the maternal conditions requiring the induction of labor 
may be noted especially the lesser degrees of pelvic contraction in 
which delivery at term is deemed impossible, while a living child 
may be obtained by an early labor. In these cases the choice is 
between the induction of labor and symphyseotomy or Cesarean 



.-•' 



section at term. (See Treatment of Contracted Pelvis, page 7 1 



In 



deciding as to the advisability of the induction of premature labor 
for flat pelvis the following measurements are to be considered: 
The biparietal diameter of the fetal head at the fortieth week is 3! 
inches (9.5 cm.) ; at the thirty-eighth week it is 3^ inches (9 cm.) ; at 
the thirty-sixth week it is 3^ inches (8.25 cm.); at the thirty-fourth 
week it is 3 inches (7.62 cm.); at the twenty-eighth to the thirty- 
second week it is i\ inches (7 cm.). (Compare page 89.) From 
these figures I deduce the following indications: When the clinical 
index of a pelvis as expressed by the true conjugate is 3I inches 
(9.5 cm.), labor may be allowed to proceed to the fortieth week; 
with a true conjugate of 3^ inches (9 cm.), labor should be induced 
between the thirty-sixth and thirty-eighth weeks; with a true con- 
jugate of 3 j inches (8.25 cm.), labor should be induced between 
the thirty-fourth and thirty-sixth weeks; with a true conjugate of 
3 inches (7.62 cm.), labor should be induced between the thirty- 
second and thirty-fourth weeks; with 2| inches (7 cm.), between 
the twenty-eighth and thirty-second weeks. With a true conjugate 
of over 3+ inches (9 cm.), labor may usually be allowed to take 
place at term (fortieth week). These rules are, however, of only 
general application, as it is impossible to determine the exact size 
of the fetal head in titero, and the determination of the duration of 
pregnancy is not always possible. Among the fetal causes not 
already mentioned are habitual abnormal size or premature ossifica- 
tion of the fetal skull and habitual death of the fetus toward the 
latter part of pregnancy. 

In addition to such well-known affections as nephritis, heart 
disease, phthisis, pernicious vomiting, and chorea gravidarum, 
numerous minor conditions have received consideration as indicating 
the necessity for premature delivery. These are as follows: Perni- 
cious anemia: A certain amount of anemia and hydremia is com- 
patible with normal gestation and delivery. But when these eoncli- 



I 



1 



Fig. 1076. — Sterile Solid Bougie, for the Induction of Premature 
Labor, Contained in Sealed Glass Tube. 



958 OBSTETRIC SURGERY. 

tions are progressive and the patient becomes worse as pregnancy advances, in- 
tervention may be justifiable; for we are not confronted with an exaggeration of 
the natural anemic state (as advances in hemology prove), but with a pernicious 
affection. Pernicious anemia occurs with greater frequency in the pregnant 
woman than in the non-pregnant, although it is a very rare accident of 
gestation. Left to itself, pernicious anemia tends to terminate in premature labor 
or fetal death with eventual death of the mother. As this affection usually 
appears when pregnancy is well advanced, an opportunity is afforded to aid the 
chances of both mother and child by intervening soon after the diagnosis is 
made. The loss of blood will be considerably less than at term, and this fact 
alone is sufficient to establish the indication. The mother is known to have 
recovered in at least one such case.* Kleinwachter, the well-known authority 
on induced labor, advises non-intervention in all cases, although he admits that 
this is but a private opinion. Recovery has also occurred without intervention, 
the latter failing notably at times to benefit the mother. Leukemia: While 
pernicious anemia may stand in some causal connection with pregnancy, the co- 
incidence of leukemia with the latter is probably a pure accident. Authorities 
are divided upon the question of intervention or non-intervention, as they 
are, again, upon the question of the alternative of abortion or premature 
delivery. Kleinwachter sums up his views as follows: Interruption of preg- 
nancy is by no means always indicated and may even be pernicious. Toxemia 
of pregnancy: Those who believe in the existence of a general toxemic state 
peculiar to pregnancy, which underlies numerous phenomena, such as salivation, 
goiter, - hyperemesis, eclampsia, etc., regard such a condition as in itself an indi- 
cation for interrupting pregnancy. This attitude appears to exist to some 
extent in America, England, and France, but such a state of toxemia is hardly 
recognized in Germany. 

In 2 200 hospital cases I found it was necessary to induce labor in 19 cases, 
or 0.86 per cent., or once in 11 5.8 cases. The indications were: eclampsia, 4 
cases; albuminuria, 4; pelvic deformity, 4; placenta prae via, 1 ; cardiac disease, 1 ; 
shoulder presentation, 1; pulmonary tuberculosis, 1 ; death of fetus, 1. The 
maternal mortality was o per cent, in the 19 cases, and the fetal mortality after 
the thirtieth week was nil. In one still-birth the operation was performed for 
dead fetus. f 

METHODS OF INDUCING ABORTION AND PREMATURE LABOR. 

Various drugs have been used; e. g., ergot, quinin, pilocarpin, ustilago, 
the oils of tansy, pennyroyal, rue, savine and parsley, sulphate of magnesia, 
and various irritant cathartics. Many of these drugs are dangerous and all 
are unreliable. They act chiefly by causing congestion of the pelvic viscera. 

Manual and Instrumental Dilatation of the Os. — Manual or instrumental 
dilatation of the cervix may of itself be sufficient to cause the premature inter- 
ruption of labor, and it is a necessary part of many of the operations designed 
for that purpose (Figs. 1081 to 1102). Since, however, it is also a part of the 
treatment of difficult labor, and is in itself a distinct and important part of 
obstetric surgery, which merits separate attention, it will be considered by 
itself. (See page 963.) 

Catheterization of the Uterus (Krause's Method) .—The vagina and cervix are 
carefully disinfected. A solid bougie (No. 17 French or 12 English) is disin- 

*Stieda: "Ctbl. f. Gynakol.," 1897. 

fNew York Maternity and Mothers' and Babies' Hospital. 



INDUCTION OF ABORTION AND PREMATURE LABOR. 



959 



fected by boiling or steaming (Fig. 1069). The patient being in the lithotomy 
position, one or, if possible, two fingers of the operator's left hand are passed 
into the cervix, which has been drawn down by a volsella forceps (Fig. 1077). 
The bougie is passed by the right hand under the guidance of the fingers in 
the cervix, between the membranes and the uterine wall posteriorly, or in 
the direction of the least resistance, great care being taken not to rupture the 
membranes or to separate the placenta (Fig. 1077). The bougie should be 
inserted to within a short distance of the fundus. Another bougie mav be 




Fig. 1077. — Introduction of a Sterile Solid Bougie into the Uterine Cavity for 
the Induction of Premature Labor. 



passed, if its introduction is easy, and a light vaginal packing of gauze will hold 
the bougie or bougies in place and protect the vaginal wall. The bougie is 
left to remain until labor is well under way. Labor usually begins in from 
twelve to twenty-four hours. In introducing the bougie after the forma- 
tion of the placenta has occurred, care must be taken to avoid separation of 
the latter, desisting from pressure and passing the bougie in another direction 
if resistance or hemorrhage is encountered. After introduction of the bougie 
the patient should remain in bed until uterine contractions begin. Now and 
then there will be a case in which active labor pains will not begin in 



960 



OBSTETRIC SURGERY. 



twenty-four hours, and then the tampon and bougie should be withdrawn, a 
vaginal douche given, and a new bougie inserted in a position opposite to the 
first. Although one introduction is generally sufficient, several are sometimes 
required to produce the desired result, and, indeed, this method in certain cases 
fails altogether, though when time is not an object in general it is to be chosen 
as the best and safest. Its chief danger is sepsis, and this is to be obviated 
by the most rigid antiseptic precautions. I am accustomed to combine Krause's 
bougie method with a gauze packing of the lower part of the uterus. The gauze, 
iodoform or plain, is rapidly run into the uterus after the introduction of the 
bougie with one of the modern cannula packers (see Fig. 1079) until slight resist- 
ance occurs. Vaginal packing is then accomplished with the same instrument, 
by simply withdrawing the end of the cannula from the os and continuing 
the packing in the vagina.. I have never known this combined method to fail 
to induce labor within twelve hours. 

The Vaginal Tampon. — This method consists in the careful and thorough 
tamponing of the vagina with iodoform gauze or sterile gauze. The method of 
tamponing is described on page 952. It gives satisfactory results only in cases 
of hemorrhage and as an adjuvant to other measures. 

Tamponade of the Vagina and Cervix. — The above method may be made 

considerably more effective by 
a preliminary tamponade of the 
cervix. After about the thir- 
tieth week artificial dilatation 
is not usually necessary. Before 
that time the cervix may be 
dilated by Hegar's dilators or 
by the cautious use of one of 
the branched dilators until it 
will admit the finger. The cer- 
vix should then be packed with 
gauze and the vagina tamponed. 
(Compare page 952.) 

Tamponade of the Uterine 
Cavity.— This method acts in the same way as catheterization of the uterus, 
but affords a greater source of irritation and is very likely to prove effective. 
The cervix is dilated if necessary, and then, by means of a uterine packer, a 
tube through whose lumen a strip of gauze is 'pushed by a carrier (see Fig. 
1078), a quantity of sterile gauze is forced between the membranes and the 
uterine walls (Fig. 1079). The membranes separate without rupture, as the 
pressure exerted upon them by the mass of gauze is distributed over a con- 
siderable area. Unlike the bougie, the gauze cannot be introduced up to the 
fundus. 

Hydrostatic Bags of de Ribes.— An excellent, method for the induction of 
both abortion and premature labor is the introduction into the lower portion 
of the uterus of a Champetier de Ribes bag, or, better, one of its numerous 
modifications, notably those of Coe and Voorhees, of New York (Figs. 1102 and 
1080)^ A certain amount of preliminary dilatation of the cervical canal is a 
necessity in this method. (Compare page 972.) 

The Intrauterine Injection of Glycerin (Pelzer's Method).— When glycerin is 
injected between the membranes and the uterine wall, the consequent exosmosis 
of fluids from the amniotic sac and the resulting shrinkage of the ovum cause 
contractions of the uterus. The direct irritation caused by the presence of the 




Fig. 1078. — Management of Inevitable Abor- 
tion. Packing the Cervical Canal and Va- 
gina with Sterile Gauze. 



INDUCTION OF ABORTION AND PREMATURE LABOR. 



961 



fluid is also a factor. This method is usually promptly effectual. It is, however,, 
open to the objection that glycerin poisoning and hemoglobinuria may result,. 
and it is contraindicated in cases of nephritis. There is also danger of the intro- 
duction of air into the uterine cavity. 

Circular Detachment of the Membranes (Hamilton's Method). — This consists 
in the digital separation of a circular area of the membranes for a short distance 
above the internal os. A certain amount of cervical dilatation is, of course, 
necessary, hence this method is more applicable in the late than in the early 
months. It is not very certain in its results, but is sometimes useful as an. 
adjuvant to other methods. 

Artificial Rupture of the Membranes (Scheele's Method). — The membranes are 
perforated by a uterine sound or similar instrument passed in and through 
the os under the guidance of the left index-finger in the vagina, and the liquor 
amnii is allowed to drain away. It is chiefly useful as an adjuvant to other 




Fig. 1079. — Induction of Abortion by the Introduction of Sterile Gauze into the 
Uterus with a Cannula Packer. 



methods. It should not be used after the fetus is viable, since the fetus is 
exposed to prolonged pressure and the mother to the dangers of "dry labor."' 
There are some exceptions to this rule, however; e. g., accidental hemorrhage, 
hydramnios. This procedure is frequently employed with criminal intentions. 

The Vaginal Douche (Method of Kiwisch). — A stream of water of a tempera- 
ture of about 106 F. is directed against the cervix with considerable force. 
This is continued for ten or fifteen minutes three times in twenty-four hours, 
and repeated according to circumstances. In itself it is extremely uncertain 
in initiating labor. Alternate cold and hot irrigation has been practised by 
some. 

Cohen's Method. — Cohen advised the injection of warm water between the 

membranes and the uterine wall, and this method, with some modifications, 

has been followed by others (Lazarewitch, Kunne) ; but cases of sudden death 

during its employment have been noted, and the method is little used at present. 

61 



962 



OBSTETRIC SURGERY. 



At one time this method was popular among the criminal abortionists of Paris, 
with disastrous results. 

Electricity. — The faradic current and even the galvanic current are some- 
times used. The objections are that the method is slow and not very reliable. 
Boyer in six cases was obliged to use from two to thirteen applications and 
the time required for induction was from two to eleven days. 

Methods Advised in Early Abortion of the First Third of Gestation. — Rapid 
method: The patient should be anesthetized and placed upon a table. After 
careful disinfection of the external genitals and vagina the anterior lip of the 
cervix is grasped by a volsella forceps and steadied by an assistant. The 
cervix is then dilated by Hegar's dilators or one of the branched dilators until 
it will admit the finger, which is then passed through the cervix while the 
external hand grasps the uterus through the abdominal wall and forces it down- 
ward in the axis of the inferior strait. The desideratum is the removal of an 
intact ovum, which cannot always be accomplished. An exaggerated lithotomy 

position and abdominal pres- 
sure are of the greatest as- 
sistance. If, however, the 
finger cannot be passed high 
^- enough to detach the ovum, 

jS* ^_~o \ an effort may be made to 

detach it by cautiously pass- 
ing a dull curette between it 
and the uterine wall, when it 
may be removed by the finger 
or ovum forceps. If this 
cannot be done, it should be 
broken up and removed by 
the curette. (The technique 
of manual and instrumen- 
tal curettage is described 
later.) The uterus should then 
be carefully but thoroughly 
curetted with the sharp cu- 
rette and washed out with a 
non -toxic antiseptic solution, 
decinormal salt solution, or boiled water. If the operation has been aseptically 
performed, gauze drainage is superfluous. Some operators prefer to remove the 
fetus and then tampon. If after twenty-four hours the rest of the ovum does not 
come away when the tampon is taken out, they curette. As a rule, it is well 
for a good operator to curette at the first sitting. It should be remembered 
that in speaking of an intact ovum I mean simply that the bulk of the ovum 
has not been broken up. It is probable that complete separation of the decidua 
vera never takes place. For this reason the use of the curette is indicated even 
when the so-called intact ovum has been removed by the finger. Slow method: 
If the physician has not the necessary instruments or mistrusts his ability or 
operative skill, catheterization of the uterus may be tried, or the ovum may be 
circularly detached with the sound, or the cervix and vagina may be tamponed, 
or the last two expedients may be used together. A satisfactory, safe, and 
fairly prompt method is to place the patient in the lithotomy position, and 
after strict asepsis of vulva and vagina, retract the perineum, seize the anterior 
lip of the cervix with a volsella forceps, slowly dilate the os with Hegar's 




Fig. 1080. — Induction of Abortion with Voorhees' 
Modification of Champetier de Ribes' Hydro- 
static Bag. 



MANUAL DILATATION OF THE CERVIX. 963 

or a branched dilator until it admits the smaller gauze packer, and then pack 
the uterine cavity with plain sterile or iodoform gauze until resistance is en- 
countered, and after packing the vagina apply a T-bandage (Fig. 1079). Separa- 
tion and expulsion of the ovum into the upper part of the vagina usually occur 
within twelve hours. It is best to follow the expulsion of the ovum with curet- 
tage. For the introduction of the gauze, anesthesia is usually unnecessary. 

Method Advised in Late Abortions of the Middle Third of Gestation. — After 
the third month, owing to the development of the supravaginal portion of 
the cervix and the commencing formation of the lower uterine segment, forcible 
dilatation without preliminary treatment is to be avoided. Catheterization of 
the uterus under strict asepsis, combined with the intrauterine tampon, is 
probably the best treatment. At this time the expulsion of an intact ovum 
is not to be expected. It is neither practicable nor safe to remove a retained 
placenta with the curette. It should be done with the fingers. The curette, 
however, is best adapted to the removal of the decidua. (See Management 
of Abortion, page 399.) (Compare accouchement force and instrumental and 
manual dilatation of the cervix, Part X.) 

Method Advised in the Induction of Premature Labor. — In this procedure 
rapidity in emptying the uterus is not to be sought for except in cases of emer- 
gency, such as eclampsia and placenta prasvia. It is best to imitate as closely 
as possible the phenomena of natural labor. Catheterization of the uterus com- 
bined with uterine and vaginal tamponade, or the insertion of a Champetier de 
Ribes bag or one of its modifications, offers the best means of exciting uterine 
contraction. Owing to the deficient vitality of premature children, however, 
great care should be used to avoid early rupture of the membranes. For 
the same reason labor should not be allowed to continue too long after rupture 
of the membranes, and a carefully conducted forceps operation, unless contra- 
indicated, is less likely to be fatal to the child than is version. After uterine 
contractions have begun the natural forces should be allowed to complete the 
delivery, if possible. If catheterization with uterine and vaginal tamponade 
has been employed, and it is not equal to the task, cervical dilatation 
may be aided by Barnes' bags or, better, by the bag of Champetier de Ribes 
or by a partial manual dilatation, and after rupture of the membranes the 
engagement of the head and its further progress may be aided by external 
pressure (Fig. n 77). If the bags of Champetier de Ribes alone are employed, 
partial dilatation of the cervix must first be secured (page 969). Occasional 
traction upon the tube leading from the bag will often hasten the onset of 
pains. In the 19 cases already referred to, labor was induced with the intra- 
uterine bougie alone in 7 cases ; with the bougie and cervical and vaginal gauze 
packing in 2 cases; with cervical and vaginal packing in 2 cases; with Barnes' 
bags in 8 cases. 



III. MANUAL DILATATION OF THE CERVIX. 

This procedure is our resource when a serious emergency, arising in the 
presence of an undilated or but partially dilated cervix, makes immediate de- 
livery a necessity. An important condition, however, should be noted. Under 
no circumstances should delivery by this method be attempted until the internal 
os has disappeared or can be readily made to disappear (Figs. 1092 to 1095). 
Such an attempt exposes the patient to the most imminent danger of rupture of 
the uterus (Fig. 799). This method also presupposes a certain amount of dilata- 



964 



OBSTETRIC SURGERY. 



tion, enough to admit the finger. It is rarely necessary, however, to resort 
to instrumental dilatation as a preliminary during the latter part of pregnancy. 
It is essential to the success of this method that the dilatation should be slow 
and gradual. Any attempt to overcome the resistance of the cervix by sudden 
force is likely to be attended by consequences of a most disastrous nature. 
As soon as the cervix is felt to contract around the finger, all efforts at dilatation 
should cease, to be resumed when it is felt to relax. The operator should 
remember that the cervix is' a muscular organ and that its relaxation can but 
gradually be effected, and that the physiological softening caused by the alternate 
advance and retreat of the presenting part (Fig. 581) is absent. 

Unimanual Dilatation. — This is the method commonly recommended and 
practised. It is not necessary to describe the various and practically unes- 
sential differences in the operation as practised by different operators and 
described in different text-books. The methods are practically the same, and 
are all based, I believe, upon an erroneous idea of the mechanism of cervical 
dilatation. Operation: Perhaps the following will serve as an average descrip- 





Fig. 10S1. — Unimanual Dilatation of the 
Parturient Os. 



Fig. 



1082. — Unimanual Dilatation of 
the Parturient Os. 



tion of the method as commonly used: One finger is passed into the os, and 
this is followed by the gradual insertion of the other fingers successively, finally 
of the thumb, and later by the expansion of the hand (Figs. 1081 and 1082). 
When the closed fist can be withdrawn through the os, the operation is regarded 
as complete. It will be observed that in this operation the natural method 
of dilatation is reversed, the dilatation during the greater part of the operation 
being from below upward rather than from above downward. Some advocates, 
of this method advise that after the closed fist has passed through the internal 
os it should be drawn down at intervals against the resisting cervical ring in 
imitation of the advance and recession of the fetal head during natural delivery, 
also that when the closed fist can be drawn through the canal the highest attain- 
able degree of dilatation has been reached. It is apparent, however, that the 
size of the closed fist is a variable quantity, and that it is by no means a standard 
of the degree of dilatation attainable by the bimanual method about to be 
described. It also seems likely that the presence of the closed fist above the 
internal os would tend to displace the presenting part, and it is also more liable 



MANUAL DILATATION OF THE CERVIX. 



965 




Fig. 1083. 






Fig. 1085. 



Fig. 1086. 




Fig. 1087. 




■^ 



Fig. 1088. 



Figs. 1083-108S. — Bimanual Dilatation of the Parturient Os. 



966 



OBSTETRIC SURGERY. 



to injure the vulnerable lower uterine segment than are the tips of the fingers 
as used in the bimanual method (Figs. 1081 and 1082). 

Bimanual Dilatation. — The method to be now considered will perhaps be 
better appreciated by a glance at the accompanying illustrations than by any 
written description. (Figs. 1083 to 1090.) Like all methods of manual dilata- 
tion it must be preceded, when necessary, by some degree of- dilatation obtained 
by one of the steel instruments, or by a tampon of gauze packed into the uterus 
and cervix. This preliminary treatment is, of course, more important during 
pregnancy than during labor. In all cases care should be taken that the pressure 
applied in dilatation is applied to the internal os, especially in those cases 
already mentioned in which this has not been effaced. 

Indications. — In placenta prccvia there is usually such slight resistance to 
be overcome that one may proceed at once to dilate with the fingers. If hemor- 
rhage becomes severe, bipolar version by the Braxton-Hicks method ma} 7 be done, 
and while the fetal leg is held by an assistant, hemorrhage being thus con- 
trolled, bimanual dilatation 
may be continued until a 
sufficient degree of dilata- 
tion is reached to permit 
extraction (Fig. 1090). Here 
the bimanual method pos- 
sesses a marked advantage 
over all others. Indeed, it 
is the only method which is 
not rendered impracticable 
by the pressure in the cer- 
vical canal of the fetal thigh 
or half breech. In eclampsia 
in pregnancy or labor when 
dilatation and softening have 
not commenced, preliminary 
treatment of the cervix will 
be necessary, and in the 
mean time such medicinal 
treatment, in the way of 
elimination, etc., as may be 
necessary should be contin- 
ued. If labor has begun and the cervix is already partially dilated, manual dilata- 
tion can be at once instituted. Manual dilatation may also be found useful in cases 
m which sudden death of the mother renders post-mortem delivery necessary, 
as, for example, in cases of maternal apoplexy or cardiac disease, in intra- 
uterine asphyxia of the fetus from any cause, in faulty presentations and posi- 
tions, in prolapse of the cord, in delayed first stage, cervical rigidity, uterine 
inertia, etc. 

I believe that there is one use of bimanual dilatation which is too often 
neglected; namely, its employment in the treatment of delayed first stage with 
reference, not to immediate delivery, but to the acceleration of labor. When 
delayed labor is due to reflex causes, — i. e., fear, excitement, pain, hysteria, 
etc.,— a short, deep anesthesia accompanied by partial manual dilatation is 
often followed by the happiest results. The temporarv use of chloroform to 
the obstetrk degree, however, or perhaps, better still,' the use of chloral, is 
usually sufficient in these cases. It is, moreover, useful in cases in which, owing- 




Fig. 1089. — Bimanual 
rient Os. — {From a 
gency Hospital.) 



Dilatation of the Partu- 
photo graph taken at the Emer- 



MAX UAL DILATATION OF THE CERVIX. 967 

to a faulty direction of the uterine axis or some slight departure from the normal 
mechanism, cervical dilatation does not progress satisfactorily. In these cases 
a partial manual dilatation is often followed by a rapid and satisfactory com- 
pletion of labor. "When used in this manner, manual dilatation is not to be 
regarded as an interference with, but rather as an assistance to, the natural 
process of labor. 

Advantages. — The advantages of the bimanual method I believe to be the 
following: (i) The chief recommendation of this operation is that it is a closer 
imitation of the natural process of cervical dilatation than any of the other 
methods which are available when immediate delivery is necessary. The pre- 





F 



'^ 




Fig. 1090. — Bimanual Dilatation of the Parturient Cervix, Carried on after the 
Bringing down of One Leg by Braxton Hicks' Method of Bipolar Version, 
for Placenta Pr.evia. 

liminary dilatation and partial softening of the cervix by the use of the cervical 
tampon or the Barnes bag causes an even closer approach to the natural process. 
(2) The membranes are preserved throughout the operation or until a full 
dilatation is obtainable. (3) There is no interference with the original presenta- 
tion and position. (4) The sense of touch of the operator's fingers is unim- 
paired. (5) There is no constriction of the operator's hands. (6) The amount 
of force exerted can be better estimated, and hence there is less likelihood 
of lacerations. (7) In placenta prsevia there is less preliminary separation of 
the placenta by this method than by any other. (8) There is less danger of 
sepsis and of injury to the lower uterine segment because of the limited amount 



968 



OBSTETRIC SURGERY. 



of manipulation within the uterus. (9) It can be performed with a presenting 

part, as the leg, in the os (Fig. 1090). 

Operation. — The patient is placed in the 
lithotomy position, the index-finger of one 
hand is introduced within the cervix, which 
is drawn upward behind the symphysis. 
(Figs. 1089 and 1083). When the dilata- 
tion is sufficient to permit the introduction 
of the tip of the other forefinger, this is 





Fig. ioqi. — Dangers of a Rapid Breech Extraction 
through an Imperfectly Dilated Os. The exter- 
nal os not being fully dilated or paralyzed, traction 
on the legs or breech results in extension of the head 
and both arms above the cervix. 



Fig. 1092. — Cervical Canal 
of the Fourth Month of 
Pregnancy Unchanged. 




introduced opposite its fellow and pressure is made by both fingers in opposite 
directions (Fig. 1084). This pressure is continued as a sort of eccentric mas- 
sage, the fingers of the opposite hands 
always making gentle and steady pressure 
outward and downward and in opposite 
directions. ■ The pressure, at first made 
antero-posteriorly, is subsequently made 
laterally and obliquely, the points on which 
the force is exerted being constantly changed 
so that all parts of the cervical ring are in 
turn subjected to it (Fig. 1086). As dilata- 
tion progresses the second finger of the 
right hand is introduced alongside of the 
first, then the second of the left hand, as 
shown in the illustrations, and progressive 
pressure continued as already described 
(Fig. 1087). After full dilatation is accom- 
plished some time should be spent in pro- 
ducing complete relaxation and paralysis of the resisting cervical ring (Fig. 
1088). After this is accomplished, however, extraction should be performed 
as quickly as possible, since the cervix is likely to recontract. 



^J 



*k 



Fig. 1093. — Cervical Canal of a 
Primipara, with Beginning Di- 
latation of the Internal Os. 
1, Internal os; 2, external os. — 
(Leopold.) 



INSTRUMENTAL DILATATION OF THE CERVIX. 



969 



I desire to protest against the rapid manual dilatation of the os; namely, 
the complete dilatation performed within an hour, before the action of the 
uterus has caused the cervix to become relaxed, at least to a certain degree. 
If the internal ring is present and in a rigid state, as is shown in Fig. 1092, pre- 
liminary treatment should be instituted by the use of a cervical dilator of 
gauze or a hydrostatic bag, that will induce a certain amount of uterine 
action with cervical dilatation and softening and cause the rings of the os to 
become sufficiently relaxed so that rapid dilatation is rendered a safe operation. 
Rapid manual dilatation may be undertaken and complete paralysis of the 




Fig. 1094. — Cervical Canal in a Primi- 
para with Beginning Dilatation of 
the Internal Os. Eclampsia. — (Leo- 
pold.) 




IN. OS 



V. EX. OS. 



Fig. 1095. — Cervix in Latter Part of 
Gestation or at Beginning of Labor. 
Vaginal and Supravaginal Portions 
of Cervix Unchanged, v., Cuff of 
vagina; ex.os., external os and infra- 
vaginal portion of cervix; c.v.j., cervico- 
vaginal junction; s.v.c, supravaginal 
portion of cervix; in.os., internal os; 
l.u.s., lower uterine segment. 



cervix attained within an hour, as shown in Fig. 1088, even when there is a 
minimum amount of uterine action or when the os is in a softened, yielding, 
and relaxing condition, although the anatomical conditions pictured by Fig. 
1094 may exist. A strictly expectant treatment in respect to emptying the 
uterus is far preferable to the attempt quickly to overcome a rigid os by manual 
means, when the supravaginal portion of the cervix still persists (Figs. 1092 
1095).* To the writer's knowledge such a procedure has ended in complete 
rupture of the uterus followed by a prolapse of the maternal intestines between 
the operator's fingers in more than one instance. 



IV. INSTRUMENTAL DILATATION OF THE CERVIX. 

Indications. — Dilatation of the os is a part of the induction of abortion 
and premature labor (see page 956). As a general rule, it may be said that 
the physician should be slow to resort to manual or instrumental dilatation 
simply for tedious labor, especially with unruptured membranes. Having satis- 
fied himself that the delay is not due to malposition or malpresentation, and 
the condition of mother and child does not require immediate interference, 

* These illustrations are from photographs of composition and plaster models, and have 
already appeared in a series of articles by me on " Methods and Aids in Obstetric Teaching," 
published in the " New York Medical Journal," Nov. 14, 21, 28, and Dec. 5, 1896. 



970 



OBSTETRIC SURGERY. 



better results will usually be obtained by the use of chloral or a light temporary 
anesthesia, and by an effort to discover and remove the cause of the delay 
(see Anesthesia, page 933, and Delayed Labor, page 625), and thus the mother 
will be saved the dangers of shock and sepsis which to a greater or less extent 
attend even a carefully conducted operation. The instruments ordinarily used 
for producing dilatation of the cervix are gauze or metal or vulcanite dilators, 
bags of rubber or silk dilated with water, and the hand. 

Uterine and Cervical Tampon. — A valuable method, although a slow one, of 
securing cervical dilatation at any time in pregnancy is to pack the lower 
uterine segment and cervical canal with iodoform or sterile gauze until moderate 
pressure is attained. The packing cannula (Fig. 1079) is most convenient for this 
operation. The vagina is subsequently packed and a T~t>andage applied and the 




Fig. 1096. — Instrumental Dilatation of the Parturient Os Preparatory to Further 
Manual Dilatation, Gauze Packing, the Introduction of Bougies for the Induc- 
tion of Labor, or Cervical Dilators. — {From a photograph of the author's model.) 



gauze left in for from six to twelve hours. This method I find invaluable as a 
preliminary to rapid manual dilatation of the os (see page 969), in cases of 
eclampsia, placenta praevia, and accidental hemorrhage, as a preparatory 
measure to cause the disappearance of the supravaginal portion of the cervix 
(internal os), and to soften the cervix and the whole lower uterine segment so that 
the subsequent rapid dilatation can be easily and safely accomplished. 

Graduated Hard Dilators. — These are made of steel or vulcanite and are 
used in somewhat the same manner as uterine sounds ; the smallest being first 
passed into the cervix and then the larger sizes successively until the dilatation 
is deemed sufficient. There are several varieties: Hanks', Hegar's, Peaslee's, 
Kammerer's, etc. Male sounds, Nos. 15 to 18 French, may often be used with 
satisfaction. Method and Operation: The patient is in the lithotomy position, the 
perineum is retracted by a speculum. The anterior and posterior lips of the cervix 



INSTRUMENTAL DILATATION OF THE CERVIX. 



971 



are drawn down by volsellum forceps. A sound shows the depth and direction of 
the cervical canal. The smallest sound is then introduced and the dilatation 
carried as far as necessary by the successive introduction of the larger ones. 

Branched Steel Dilators (Fig. 1096). — This kind of dilatation, so useful in 
gynecological practice, has hitherto played but a minor role in the department 
of obstetrics. The branched steel dilators heretofore in use have been of service 
only in cases in which a tightly closed external os rendered their use necessary 
as a preliminary to other methods of dilatation. Dilatation is effected by passing 




Fig. 1097. — Bossi's Dilator for the Par- 
turient Cervix. 



Fig. 1098.- 



-Gau's Dilator for the Par- 
turient Cervix. 



the closed instrument into the cervix and separating the branches by compres- 
sion of the handles, applied either directly by the hands or through the 
medium of a screw. Sims' and Ellinger's may be regarded as types. There 
have been various modifications. Recent work on the use of large obstetric 
steel dilators, however, has opened up new possibilities in this direc- 
tion. One of the more recent steel obstetric dilators is the four-bladed one 
of Bossi (Fig. 1097). It is probably the best instrument now at our disposal. 
Steel instruments are, of course, more easily rendered aseptic than is the hand. 



972 



OBSTETRIC SURGERY. 



It is difficult, however, to estimate the amount of force used, nor is a steel instru- 
ment so perfectly under the operator's control. It is safe to say that, as an imi- 
tation of the natural process, and therefore as a safe method of dilatation, no 



*sA 





Fig. 1099. — Barnes' Rubber Hydrostatic Dilator in Position in the Cervix. 




Fig. 



-Champetier de Ribes' Hydrostatic Cervical Dilator in Position in the 

Lower Uterine Segment. 



steel instrument at present devised can be used which will take the place of the 
dilating bags in cases which permit slow dilatation, or of the bimanual method in 
cases of great emergency. Method of Operation: The position of the patient and 
the preliminary manipulations are the same. The closed branches of the dilator 



INSTRUMENTAL DILATATION OF THE CERVIX. 



973 



are passed as far as the shoulders. The blades are separated laterally, then the in- 
strument is rotated and they are separated antero-posteriorly. Dilatation should 
be very slow and gradual. Force is used to cause the cervix to yield, not to 
tear; and the less force which will accomplish the purpose, the better. 

Hydrostatic Dilators. — These are of rubber or silk, are hollow, and are dis- 
tended after their introduction by means of water which is forced into them 
with a Davidson syringe. The best known in this country and England is 
the water-bag of Barnes (Fig. 1099). The bag is of rubber, is fiddle-shaped, 
and is made in three sizes. A fourth and larger size may sometimes be used 
with advantage. McLean's bag 
is a modification of Barnes', and 
is provided with two chambers 
and two tubes, so that after one 
compartment is distended the 
other can be filled and dilatation 
continued without the removal 
of the bag. The bag of Cham- 
petier de Ribes (Fig. 11 00) is 
made of rubber but has a silk 
lining to prevent bursting. It is 
in the shape of a cone, the larger 
end being introduced first. When 
distended with water, nature's 
method of dilatation, is some- 
what closely imitated. This is 
especially true of the bag of 
Champetier de Ribes and its 
modifications, and the colpeu- 
rynter of Diihrssen. These well- 
known instruments, which have 
the shape of a funnel or an in- 
verted cone, may be drawn into 
the cervical canal and against 
the internal os in a manner 
closely simulating the method of 
nature. With regard to the 
water-bags of Barnes, it should 
be noted that they are much 
more efficient and more likely to 
remain in place when the cavity 
of the cervix is preserved, than 

when only the external os is present, as is so frequently the case in primiparas. 
While the Barnes bag is often very serviceable, I regard the de Ribes bag or its 
modifications as preferable for the following reasons: (1) The natural process is 
more closely imitated, the cervix being dilated from within outward according to 
the natural process. (2) The bag does not slip out. (3) By gentle traction 
upon the tube one can cause uterine contraction and assist in dilatation if 
necessary. (4) The bag is not likely to burst. (5) It is a valuable agent in 
prolapse of the funis or fetal small parts, in premature rupture of the mem- 
branes, in placenta praevia and other complications. 

Method of Introducing the Soft Dilators. — A certain amount of dilatation is 
presupposed. The dilator should be folded upon itself, lubricated with a 1 per 




Fig. iioi. — Voorhees' Modification of Cham- 
petier de Ribes' Hydrostatic Cervical Dila- 
tors. Two Sizes Shown. 



974 



OBSTETRIC SURGERY. 



cent, lysol solution, seized with a pair of long dressing forceps, and passed 
within the cervix until the constricted part, if a Barnes bag is used, is at the 
internal os, or until half the bag, if a de Ribes bag is used, is within the internal 
os. The Barnes bag is provided with a pocket into which a sound may be 
inserted and the bag passed into the cervix with the sound. The first method, 
however, is more satisfactory. Bags should not be distended with air, since 

their rupture may then be attended with 
serious consequences. Water should be used 
and should, of course, be forced in slowly 
and gradually. In using the Barnes bag, 
when the smaller-sized bag has been ex- 
pelled, the next larger one should be in- 
serted if necessary. With the de Ribes bag 
no change is necessary unless one uses 
graduated sizes, which may now be obtained 
of the instrument-makers in New York. In 
every instance when a hydrostatic cervical 
dilator is used, the bag should be carefully 
tested before introduction. This is done by 
forcing a given number of bulbfuls of water 
from a Davidson syringe into the bag so as 
fully to distend it; then, if the bag remains 
intact, it is introduced and to insure against 
rupture one bulb less of water is pumped in 
than in the test examination. I have in 
two instances seen rupture of the uterus, 
as proved by autopsy, caused by the intra- 
uterine explosion of an overdistended Barnes 
bag. The large Champ etier de Ribes dila- 
tors, as originally sold, should be avoided, and only the smaller ones used. The 
former occupy too much space in the lower uterine segment, change its shape, 
and favor malpresentation of the fetus. In my practice I observed a vertex 
presentation changed thus to a shoulder, for which I was compelled to per- 
form an internal podalic version. 




CERVIX— 



Fig. i 102. — Coe's Modification of 
Champetier de Ribes' Hydro- 
static Cervical Dilator. 



V. MANUAL AND INSTRUMENTAL DILATATION OF THE 
VAGINA AND VULVA. 

Indications. — Occasionally in very old or very young primiparae, in cases 
of cicatrices from previous inflammation and ulceration, in malignant disease 
and thrombosis, artificial dilatation of the vagina may be demanded. I have 
occasionally been compelled to employ this operation in elderly primiparae 
and in the very young. In cicatricial stenosis of the vagina, dilatation by the 
fingers or hydrostatic dilators may occasionally be required, but in most cases 
the natural forces will overcome the obstruction, even when the original opening 
would admit but one finger. In cases in which the vagina is simply small and 
rigid — e. g., in very young or in old primiparae — the resistance is chiefly at 
the lower third, and the case should be left to nature as long as is judged safe. 
A carefully conducted forceps operation with very slow extraction is then to 
be considered as the best means of effecting further dilatation. If even this 
bids fair to produce severe laceration, or if rapid delivery is imperative, episi- 



INCISIONS OF THE CERVIX, VAGINA, AND VULVA. 975 

otomy (g. v.) may be required. In certain cases of a small and rigid vulva and 
lower third of the vagina surprisingly good results may be obtained by manual 






dilatation, one or two fingers being introduced into the posterior commissure 
followed by intermittent backward massage-like pressure (Fig. 1103). 



VI. INCISIONS OF THE CERVIX, VAGINA, AND VULVA. 

1. Superficial, and 2. Deep Incisions of the Cervix. — (1) Superficial multiple 
incisions: These as well as deep incisions are required only in exceptional cases, 
and are especially liable to extend and involve the branches of the uterine 
artery. Superficial incisions or nicks in the cervix are indicated only when the 
use of chloral or some other anesthetic has failed, and when manual dilatation 
without the use of a dangerous degree of force does not succeed. This most 
often occurs in rigidity of the portio vaginalis in old primiparas, and in multiparas 
when several years have elapsed since the birth of the last child. There is 
a lack of elastic tissue, or atrophy of the elastic fibers has already begun. It 
may also be indicated in cases of atresia in which the os cannot be opened 
by the finger or dilator. In this case, if the os cannot be located, the stretched 
cervix may be raised by tenacula at its thinnest point, and a crucial incision 
made. The superficial incisions are made by a blunt-pointed bistoury or a 
pair of blunt-pointed scissors. During a pain, the patient being in the 
lithotomy position, the instrument is carried into the vagina under the 
guidance of the fingers, and the stretched cervical rim is incised in several 



976 



OBSTETRIC SURGERY. 



places to the depth of 0.5 cm. (Fig. 11 04). Dilatation sometimes occurs with 
surprising rapidity after this procedure. Care should be taken that such 
incisions are really superficial, since when carried further they are likely to 
extend and to result in disastrous lacerations of the lower uterine segment. 
(2) Deep incisions: Incisions of the cervix extending to the utero-vaginal junc- 





Fig. 1 104. — Multiple Superficial In- 
cisions of the External Os. 



Fig. 1 105. — Deep Incisions of the Par- 
turient Cervix, Extending from the 
Border of the External Os to the 
Utero-vaginal Junction. 



tion and involving the entire vaginal portion were first proposed by Skutsch 
and first performed by Duhrssen. Indications: Those usually given are: any 
emergency which requires immediate delivery in the presence of an undilated 
and rigid cervix; e. g. f eclampsia, accidental hemorrhage. The operation should 
not be performed until the supravaginal portion of the cervix has disappeared, — 
in other words, when the defective dilatation is confined to the vaginal portion 




A 




Fig. i 106. — Effect of the Four Deep 
Incisions of the Cervix upon Dilata- 
tion. 



Fig. 1 107. — Author's Case of Deep 
Bilateral Incisions of the Cervix 
Thirteen Months after Delivery. 
Partial Repair Has Taken Place 
in the Bilateral Incisions. 



of the cervix, — and is, therefore, much more frequently indicated in primiparae. 
In multiparas mechanical dilatation is usually sufficient. In the presence of 
immediate danger, however, the supravaginal portion still being present, the 
two procedures may be combined with advantage; that is, mechanical dilatation 
until the internal os has been obliterated and rapid completion of the dilatation 
by deep incisions. There is one condition in which they should always be 



INCISIONS OF THE CERVIX, VAGINA, AND VULVA 



977 



avoided; namely, in arrest of the after- 
coming head during breech delivery, or 
after version in multiparae. Here the re- 
sistance is at the internal os, and any but 
the most superficial incisions would be likely 
to result in extension to uterine rupture dur- 
ing the process of delivery. Operation: The 
patient being in the lithotomy position, the 
free edge of the os is fixed between two 
bullet forceps, and under the guidance of 
the index and middle fingers of the left 
hand, one within and the other without 
the cervix, the vaginal portion of the cervix 
is incised by a pair of long, blunt-pointed, 





•V* 




**m 



Fig. 1108. — Episiotomy.- 
62 



"he face presentation is from a pi 
taken at the Emergency Hospital.) 



graph of the author's case 



978 



OBSTETRIC SURGERY. 







straight or angular scissors or a bistoury, care being taken that the incision 
is brought fully up to the utero-vaginal junction. If the incision stops 
short of this point, full dilatation does not take place and extension 
beyond the vaginal attachment may occur from tearing. Care should be taken 
that a fold of vagina is not included in the incision, since this, in case of the 
posterior incision, might open into the pouch of Douglas, or in case of the 
anterior incision might involve the utero- vesical pouch or even the bladder. 
The same mistake in the case of a lateral incision might result in severing a 
ureter. Four incisions are usually made, two antero-posterior and two lateral 
(Figs. 1 105 and 1106). Suture is not necessary except in case of severe 
hemorrhage, which should not occur if the incisions have been properly made. 
Spontaneous union of the edges usually occurs. The risks of septic infection 
are the same as in any other internal obstetric procedure. The field of this 
operation is most limited. The operation itself is a serious one and not lightly 

to be undertaken. In all but ex- 
ceptional cases rapid bimanual dila- 
tation of the os, or rapid bimanual 
dilatation of the os combined with 
these incisons, will fulfil all indica- 
tions. 

Incisions of the Vagina. — These 
are most often called for in cases of 
cicatricial contraction or congenital 
defects, and are best made along the 
lateral vaginal wall with a blunt 
bistoury. A comparatively large 
number of shallow incisions are to 
be preferred to a few deep ones, 
since there is less danger of hemor- 
rhage. Lateral incisions are to be 
preferred to anterior or posterior 
ones, when possible, since the latter 
may involve important structures — 
bladder, peritoneum, rectum. In 
all cases, however, labor may usually 
be terminated either spontaneously 
or by the use of forceps or version, 
with manual dilatation of the vagina 
without using the knife. Cases 
of unyielding circular cicatricial contraction may be treated by a cruciform 
incision. 

Incision of the Vulva. Episiotomy. — Definition: The operation of making 
lateral incisions in the vulva in order to avoid laceration of the perineum. 
Indications: It is indicated when delivery without severe perineal laceration is 
deemed impossible — usually in cases of great disproportion in size between the 
fetal head and vulval outlet. It is seldom necessary, however, and in the 
absence of cicatricial contraction better results will usually be obtained by 
awaiting the natural process of dilatation. Operation: The operator should 
remember that it is not the border of the vulva which resists the progress of 
the head, but the tense ring situated about half an inch above. During a pain 
this ring is readily recognized about half an inch above the muco-cutaneous 
junction. The incisions should not be in the line of the vulvo-vaginal outlet 
as it appears during the stage of expulsion, or it will be found after delivery 



Fig. 



1 109. — Deep Vaginoperineal Incisions 
for Small and Rigid Vagina. 



INCISION OF THE CERVIX, VAGINA, AND VULVA. 



979 



that they have been directed too far backward. They should be made in a 
direction corresponding to the long axis of the mother's body as she lies in 
the recumbent position. Under the guidance of the fingers a blunt-pointed 
bistoury is passed flat-wise against the resisting ring, then turned, and the 
ring incised from within outward. The incision should not exceed an inch 
in length and its depth should be about a quarter of an inch. It should be 
made at a point about one-third of the distance from the posterior to the anterior 
commissure when the parts are on the stretch. In this location the only parts 
severed are the skin, fascia, and perhaps the bulbo-cavernosus muscle (Fig. 




k 



Fig. iiio. — Manual Correction of Brow and Face Presentation. Rotation of the 
head upon a transverse diameter to produce flexion with the internal hand, and down- 
ward pressure upon the occiput with the external hand. (Baudelocque's method.) 



1 1 08). If preferred, the incision may be made with blunt-pointed scissors 
(Fig. 1 108). Care should be taken that the head is not suddenly forced out 
during the operation. For this reason it is better that the incisions should 
be made at the beginning or toward the end of a pain, and that the progress 
of the head be retarded if necessary. After delivery the incisions are at once 
closed by suture. In suturing it is convenient that the mother lie upon the 
right side while the left incision is being sutured, and vice versa. In this way 
the field of operation is kept clear of blood. 

Vaginoperineal Incision. — Duhrssen advises in some cases of small and 



980 



OBSTETRIC SURGERY. 



rigid vaginae in which immediate delivery is urgent, incisions which divide 
not only the constrictor cunni but the levator ani. These^ he calls vagino- 
perinear incisions. He advises that when possible only one incision be made. 
This method has thus far not met with general approval (Fig. 1109). 



VII. CORRECTION OF FAULTY POSTURE, MALPOSITIONS, 
AND MALPRESENTATIONS. 

1. Manual Correction of Bregma, Brow, and Face Presentations.— ( 1 ) Schatz 
External Method: This method is limited to those cases in which the head 



- 




Fig. 1 hi. — Manual Correction of Face, Brow, and Bregma Presentation. ' The 
internal hand rotates the head upon a transverse diameter by drawing down the occiput, 
and the external hand pushes the anterior shoulder to the side toward which the dorsal 
plane lies. Thorn's method.* 



is not engaged and is freely movable; the membranes are unruptured, or if 
ruptured the fetus is readily moved about in the uterus ; and there is no imme- 
diate demand for the rapid termination of labor. The -method is only exception- 
ally successful, there having been many failures, and by reason of the conditions 
necessary for its performance, has a very limited field, being confined mainly 
to maternity hospitals, where the anomalies are recognized early in labor.. 
* Thorn: "Zeit. fur Gynecol, v. Geburts.," xm, 186. 



CORRECTION OF FAULTY POSTURE. 



981 



Although Schatz describes his method as applicable to face presentations, from 
a mechanical standpoint it is also applicable in bregma or brow presentations. 
Operation: Anesthesia is not always required. The patient is placed in the 
dorsal posture with knees partly drawn up; the operator stands on the side 
toward which the occiput is directed. Between uterine contractions one hand 
grasps the breech and one the anterior shoulder, and an even, strong pressure 
is made upon the shoulder toward the occiput and somewhat upward; the 
breech is at the same time pushed upward with the other hand and also toward 
the abdominal surface of the fetus; finally, the breech is pressed downward. 




Fig. i 112. — Combined Manual Method for the Correction of Face and Brow Pres- 
entations. Schatz-Thorn Method. 



During the uterine contractions all manipulations cease and the head is grasped 
through the abdominal walls and fixed. After the occiput is brought over 
or into the pelvic inlet, the membranes maybe ruptured and the head held until 
engagement occurs (Fig. 692). (2) Combined External and Internal Method : 
If the above method fails, which is pretty sure to be the case, one of the following 
can be tried, (a) Digital pressure: In bregma and brow, and occasionally in 
face presentations, passing two or three fingers into the vagina and pressing 
up upon the bregma, brow, and at the same time using counter-pressure with 
the whole of the remaining hand upon the breech of the fetus, will often rotate 



1 1 



982 



OBSTETRIC SURGERY. 



the fetal head upon its transverse axis (Fig. 1112). In this method the dorsal 
posture with flexed thighs is used for the patient, and the operator stands or, 
better, sits on the side of the patient toward which the occiput points, (b) 
Lifting of the brow and face: With the same positions of patient and operator, 
but under anesthesia, the hand, the palm of which corresponds with the fetal 
face, is passed into the vagina and grasps the forehead or face and carries it 
away from the pelvic inlet in the direction of the fetal chest, while the external 



''■-%- 




Fig. 1 1 13. — Manual Correction of a Persistent Mento-posterior Position by Manual 
Anterior Rotation of the Fetal Chest and Chin. 



hand presses the occiput down, through the abdominal walls, into the pelvic 
inlet (Fig. 11 10). Before the internal hand is removed the operator must satisfy 
himself that the large fontanelle is actually higher than the small one, and that 
the vertex is about to engage. In difficult cases the Trendelenburg posture will 
be of great assistance. Humphrey used the knee-elbow posture for the patient, 
(c) Drawing down the occiput {Thorn's method) : The posture of the patient is 
the same as above, but the operator sits or stands on the side toward which 



THE VECTIS—THE FILLET. 



983 



the fetal abdomen points. The hand, whose palm would naturally grasp 
the occiput, is passed into the vagina, and draws down the occiput with 
an even traction, while at the same time the external hand pushes the chest 
of the fetus, or rather the shoulder, to the side toward which the dorsal plane 
lies (Fig. 1073). The Trendelenburg posture will greatly aid this manipulation. 
(d) Combined methods: In very difficult cases a combination of Schatz's and 
the method of drawing down the occiput by internal manipulation has been 
successful (Fig. 11 12). 

2. Persistent Occipito-posterior Position. — (See Pathology of Labor, page 
603.) 

4. Persistent Mento-posterior Position. — (See Pathology of Labor, page 
603.) (Fig. 1113.) 

4. Reposition of Prolapsed Cord. — (See Pathology of Labor, page 577.) 

5. Reposition of Prolapsed Arms and Legs.— (See Path- 
ology of Labor, pages 572 and 574.) 



VIII. THE VECTIS. 

The vectis was one of the simplest forms of instruments 
used for extracting or changing the position of the fetal 
head; it antedated the forceps, and has practically been 
abandoned as an instrument by itself, in favor of the 
forceps, which has proved both safer and more effective. 
The principle of the vectis is still used in obstetrics, how- 
ever,, by utilizing one blade of the forceps, and from time 
to time attempts have been made to revive interest in the 
value of the original instrument.* It resembles a single 
blade of a pair of straight forceps except that the cephalic 
curve is much more pronounced, especially near the ex- 
tremity of the instrument, in order to permit of a better 
hold of the head (Fig. 11 14). The vectis was used as a 
lever and a tractor, and some of the English writers f 
still recommend its use in persistent occipito-posterior posi- 
tions and brow presentations. In the former case it was 
used as a combined lever and tractor to favor anterior rotation, and in the 
latter as a tractor to convert the brow into a veitex or face. I believe the 
forceps to be a safer and more efficient instrument for the first purpose, and 
the hand of the obstetrician for the second. 





Fig. 1114. — The 
Copeman Vectis. 



IX. THE FILLET. 

The whalebone fillet, consisting of an inverted U-shaped piece of whalebone 
joined at the extremities of the U by a handle, is an instrument intended to 
rotate the head upon its transverse axis, thus producing either flexion or exten- 
sion, as desired, by traction upon one pole of the head (Fig. 1115). The instru- 
ment antedates the forceps, and is now, perhaps with less justice than the vectis, 

*Bartlett, John: "Ths Vectis." " The Clinical Review," Chicago, Nov., 1900 
tGalabin: "A Manual of Midwifery," London, 1900, p. 612. 



984 



OBSTETRIC SURGERY. 






considered obsolete. Placed over the chin to produce extension of the head by 
traction on the handles, the instrument was liable to injure the fetus, and its 

hold on the occiput to increase flexion of the head 
was always uncertain and dangerous by reason of 
the tendency of the fillet to slip. As in the case of 
the vectis, the hand of the obstetrician passed into 

\ the vagina combined with bimanual manipulation 
will do all and more than the fillet. (See page 980). 

|i The contingency might possibly arise when in the 
absence of instruments an improvised fillet of whale- 
bone or wire could be used to flex the extended head 

r") of a dead fetus, and possibly of one living. 




X. REPOSITION OF SMALL PARTS. 

i. Umbilical Cord. — (See page 577.) (Also Figs. 
1116 to 1122.) 

2. Other Small Parts. — If in the course of labor 
in cranial presentations with unruptured membranes, 
some small part — the hand for example — prolapses, 
it will almost always be found at the facial side of 
the head. Reposition can usually be effected by 
placing the woman on the side opposite that of the 
prolapse, and when the head is allowed to reengage the obstacle will be out of the 
way. (1) In case the membranes have ruptured and a hand or arm has pro- 



Fig. 1 1 15. — The Fillet. 

— (Galabin). 



X 




Fig. 1 i 16. — Manual Reposition of a Prolapsed Cord. 



lapsed, reposition may often be effected by a simple manipulation, if the os is 
fully dilated and the head high up. The woman is placed in the latero-prone 



REPOSITION OF SMALL PARTS. 



985 



position (Fig. 1061) and the operator introduces his hand into the vagina and 
endeavors to conduct the prolapsed part up along the face. The woman should 
lie on the side opposite the prolapse until the head engages. If this manceuver 
fails, the operator may sometimes leave the case to nature. In a roomy pelvis 
it is quite possible for the head and an arm to engage at the same time. But 
if the pelvis is contracted or if an indication arises to terminate labor at once, 
podalic version may be attempted if the head is movable, but otherwise, forceps 
delivery. In prolapse of a foot in head presentations, which is very rare, the 
indications are similar. (2) Should the head be well down in the true pelvis, 




Fig. 



1117. 



•Instrumental Reposition of a Prolapsed Cord, 
chest Posture of the Patient. 



Assisted by the Knee- 



an expectant treatment should be followed; and if any immediate danger 
threatens, such as delayed labor from obstruction or oedema of the leg, extraction 
of the head with the forceps should be done, taking care not to include the pro- 
lapsed leg. Impaction in the case of a dead fetus of course calls for perforation. 
(3) When the head is movable at the pelvic inlet or extra-medial by reason 
of the prolapsed leg filling in one side of the pelvis, and the leg constitutes 
an actual obstruction, manual reposition should be performed. In any event, 
the^existence of twins must; be borne in mind, as one may present by the head 
andthe other by the leg or foot. The patient is placed in the lithotomy position 



986 



OBSTETRIC SURGERY. 






Fig. iii8. — English Catheter Fig. i 119. —English Catheter and Loop of Tape 
and Sling for Reposition of for Reposition of a Prolapsed Cord. 

Prolapsed Cord. 



fE> 






Fig. i i 20. — Simple LongTFor- 
ceps Used to Replace a"Pro- 
lapsed Cord. 



9 

Fig. 1 121. — Whale- 
bone or Metal 
Repositor and 
Sling. 




Fig. 1122. — Whalebone Re- 
positor for a Prolapsed 
Cord. 



REPOSITION OF SMALL PARTS. 987 

or, better, on her side (compare prolapse of cord and arm), and the foot or 
knee is seized with the whole hand and pushed upward past the head; at the 
same time a hand on the fundus presses the head into the pelvic inlet from 
without. Anesthesia is necessary, and in some difficult cases the exaggerated 
semi-prone, Trendelenburg, or knee-chest position will be required. After re- 
position the dorsal position will give as satisfactory results as either of the 
lateral, provided the head is kept applied to the pelvic inlet by pressure on 
the fundus until engagement takes place. (4) In case manual reposition fails 
the head may be pushed up and version and extraction promptly performed, 
the possibility of the existence of twins, and of the presentation of one by the 
head and of the other by the leg, being always remembered. 



XI. VERSION. 

Definition. — By version is meant the changing of the presentation of the 
fetus so that one or the other of the two poles of the fetal ellipse is substituted 
for a given presentation. 

History. — Version is one of the most ancient of the obstetric operations, 
and before the invention and introduction of the forceps was used much more 
frequently than it is at present. Cephalic version was the first variety used, and 
is said to have been recommended by Hippocrates and employed even in pelvic 
presentations. Before the sixteenth century it was practically the only version 
used, but at that time podalic version was introduced, and because of the ease 
of its performance became very popular, and on this account cephalic version 
was almost entirely abandoned, although more recently revived by some obstet- 
ricians. 

Classification. — Version is usually classified, first, according to the part of 
the fetus which is caused to present at the pelvic inlet, into cephalic version, 
podalic version, and pelvic version. The last of these, namely, pelvic version, 
is to-day rarely, if ever, performed. Version is again subdivided, according to 
the mode in which it is performed, into three varieties' — namely, external ver- 
sion, combined external and internal or bipolar version, and internal version. 
External version is performed by external manipulation only; combined exter- 
nal and internal or bipolar version by the use of one hand introduced into the 
vagina and one or more fingers into the uterus to move one part of the fetus, 
while the other hand upon the anterior abdominal wall moves another por- 
tion of the fetus, thus assisting the internal fingers. Internal version is ac- 
complished by passing the whole hand into the uterus to grasp some part of 
the fetus, usually the feet, and the other hand is used on the abdomen to 
steady the fetus and assist the internal hand as far as ^possible. (See table on 
page 988.) 

Frequency. — In 2200 confinements in Xew York hospitals I found that 
version was performed in 44 instances, or 2 per cent., or once in 50 labors. 

Indications. — In the 44 versions referred to, the indications were: de- 
formed pelvis in 11 cases; shoulder presentation in 7; shoulder presentation 
and prolapsed cord in 3 ; persistent occipito-posterior position in 2 ; placenta 
praevia in 6 ; prolapsed cord in 3 ; prolapsed cord and hand in 1 ; prolapsed hand 
in 1 ; deformed pelvis and albuminuria in 1 ; deformed pelvis and shoulder pres- 
entation in 2; uterine inertia in 2; prolapse of leg in vertex presentation in 1; 
brow presentation in 1 ; hydrocephalus in 1 ; albuminuria in 1 . 



988 



OBSTETRIC SURGERY. 



Varieties. — Of the 44 cases analyzed, 35 were of the internal podalic variety; 
3 bipolar; 6 not recorded. 

CLASSIFICATION OF VERSION. 



Parts Caused to Present. 



(A) Cephalic Version 



(B) Podalic Version. 



Mode of Performance. 



Employed. 



n 1. External Cephalic. Occasionally. 

j I 2. Combined External and Internal Occasionally. 
1 j _ Cephalic (Bipolar), 



3. Internal Cephalic. 



Rarely. 



1. External Podalic. Rarely. 

2 . Combined External and Internal Frequently. 

Podalic (Bipolar). 

3. Internal Podalic. Most frequently. 



1. External Pelvic. Rarely. 

\ r> i,r~ \r :™ ) 2 - Combined External and Internal Rarely. 

Pelvic (Bipolar). j 

3. Internal Pelvic. ! Obsolete. 









Introduction of the Hand in Version. — The hand and forearm, being thor- 
oughly aseptic, are enclosed in a rubber glove and well lubricated with 1 per 

cent, lysol or creolin solu- 
tion. The fingers of the 
hand to be introduced are 
HJHk then brought together in 

the form of a cone, and 
the labia separated by the 
thumb and first and second 
fingers of the disengaged 
hand (Fig. n 23). (Com- 
pare vaginal examinations, 
page 153.) The apex of 
the cone-shaped hand is 
then pushed into the os- 
tium vaginas, and entrance 
is effected by pressing 
steadily inward and back- 
ward upon the distensi- 
ble perineum. No sudden 
movements or haste should 
be used, and ordinary rota- 
tion and boring-like move- 
ments of the hand are 
unnecessary and increase 
the tendency to laceration. 
Patience and lack of haste 
are important factors for success and avoidance of lacerations, especially in 
primiparous patients. After the hand is well in the vagina the cervix is 
sought, and in combined or bipolar version one, two, or three fingers are care- 
fully inserted through the os according to circumstances. In internal version 
the hand is passed through the os in practically the same manner as through 




Fig. 1 123. — Introduction of the Hand in Internal 
Version. Note that the vulva is widely separated and 
that the entering ringers strongly depress the perineum. 



VERSION. 



989 



the vulval orifice, but in all cases at this point in the passage of the hand the 
fundus should be steadied and even pushed down with the external hand to 
avoid dangerous stretching of the lower uterine segment, or too great traction 
of the uterine attachments by the upward pressure of the internal hand. 
The subsequent use of the fingers in combined version, and of the hand in 
internal version is described under the proper sections. 




(A) CEPHALIC VERSION. 

Cephalic version is not applicable to cases in which rapid delivery is desired, 
nor in cases of decided flattening of the pelvis unless the delivery is to be by 
symphyseotomy and forceps, for in head-first deliveries in flattened pelves we 
lose the decided advan- 
tage secured by breech 
extraction and the en- 
trance of the head into 
the pelvic inlet base first. 
Theoretically cephalic ver- 
sion is to be preferred to 
podalic version in all but 
a few exceptional cases, 
because, as has been 
stated before, the prog- 
nosis for the fetus is 
always better in cases in 
which it passes head first 
through the pelvis than in 
either spontaneous or arti- 
ficial feet-first labors. On 
the other hand, the dex- 
terity on the part of the 
operator required for its 
performance, the ease with 
which podalic version can 
usually be performed, and 
the frequent necessity for 
rapid extraction after ver- 
sion, have unjustly kept 
cephalic version in the 
background. 

Indications. — These are 
very limited, principally in shoulder and breech presentation, but not when 
rapid delivery is demanded, and hence the method is unsuitable in placenta 
praevia and prolapse of the cord. 

I. External Cephalic Version. — Indications: Cephalic version by external 
manipulation only is chiefly applicable to cases of shoulder presentation or 
oblique positions of the fetus in the uterus, discovered in the latter part of preg- 
nancy or at the onset of labor. Under favorable circumstances it may also be 
used to convert a pelvic into a cephalic presentation. After labor has com- 
menced this method may be used if sufficient liquor amnii remains and the 
uterus sufficiently relaxes between the pains. Operation: The dorsal posture of 




Fig. i 124. — External Cephalic Version in Breech 
Presentation. Note that the head is made to take 
the shortest road to the pelvic inlet. 



H 



990 



OBSTETRIC SURGERY. 



the patient with the pillows removed is to be preferred. As much relaxation 
of the abdominal muscles as possible must be secured by flexing the thighs. 
Anesthesia usually is not necessary, but in nervous patients may be required, 
and employed to advantage. For success it is necessary to make out with certainty 
the existing position and presentation of the fetus, this being done by both 
external and internal palpation. Before the operation is begun a clear mental 
picture should also be formed of just what is to be done. In shoulder presenta- 
tions and oblique positions of the fetus it is always desirable to have the head 
take the shortest road to the pelvic inlet, and in pelvic presentations we should 
aim to have the fetus revolve occiput first about the pelvis in order to avoid 
unnecessary extension of the head, provided this can readily be accomplished. 
With the palm of one hand upon the breech and the other upon the head 

the breech is carefully 
pushed up, the head 
down, until the long axis 
of the fetus corresponds 
to that of the uterus and 
the head lies over the pel- 
vic inlet (Figs. 1124 and 
1 1 25). Revolution of the 
fetus is often readily 
performed, especially in 
shoulder presentations, 
but, the cause of the 
malpresentation existing, 
return of the fetus to its 
original presentation often 
occurs; this I have found 
especially true of pelvic 
presentations. In such 
cases I have found a pad 
on each side of the uterus 
to hold the fetus in place 
of little use before labor 
actually sets in, but the 
case should be carefully 
watched and reposition 
again performed at the 
onset of labor and the 
fetus held in position until 
engagement occurs. In private practice I once thus changed a shoulder into 
a vertex presentation in the beginning of the first stage and held the head 
at the pelvic inlet by grasping it with one hand externally for three hours, 
when it finally engaged. No further anomaly occurred and the patient and 
fetus were thus saved from the dangers of a podalic version. In general, after 
correction of the malpresentation it is advisable to keep the patient quiet in 
bed in the dorsal posture so that the fundus uteri shall not incline to one side 
or the other until the desired presentation becomes engaged and fixed in the 
pelvis. Fixation of the head in the pelvic inlet may be hastened and promoted 
by artificially rupturing the membranes, as soon as the dilatation of the os 
warrants it. 

II. Combined or Bipolar Cephalic Version. — Various methods of performing 




Fig. i 125. — External Cephalic Version in Shoulder 
Presentation. 



VERSION. 991 

version by one hand passed into the vagina, one or more fingers of which being 
passed through the os, and the other hand upon the anterior abdominal wall, 
have been described by Busch, Hohl, Wright of Cincinnati, and Braxton Hicks 
of England.* The method as now usually practised is according to the principles 
laid down by Braxton Hicks, although priority has been claimed for Wright, 
of Cincinnati. f Posture of the patient: Usually the dorsal posture is more con- 
venient for both operator and patient. Hicks advises a choice of lateral position 
to assist by gravity the performance of the operation. Thus, in shoulder pres- 
entation with the fetal head to the patient's left side, and the breech therefore 
toward the right, Hicks advises the left lateral posture of the patient, so that 
the effect of gravity upon the fundus will assist in the operation by carrying 
the breech to the left and the head thus over the pelvic inlet. The reverse 
may be tried when the fetal head is to the mother's right. As in other varieties 
of version, so here, the knee-chest postuie of the patient has been recommended 
and used to assist in the recession of a partially fixed shoulder or breech. This 
posture I have found difficult for the patient to keep for any time, and not 
more efficient than the exaggerated left latero-prone posture, which any patient 
can easily assume (Fig. ic6i). The right and left exaggerated latero-prone 
posture can be used as directed. For ordinary cases the dorsal posture will be 
found the most convenient. 

In Shoulder Presentation. — It is in this presentation more than in pelvic 
that combined cephalic version is used. The term "bipolar" cannot, strictly 
speaking, be applied to combined cephalic version in shoulder presentation until 
the latter part of the procedure, when both poles of the fetal ellipse are grasped. 
Anesthesia is not always necessary but usually desirable, and it certainly facili- 
tates the operation. As in all varieties of version, a certain diagnosis of the 
exact position of the fetus is necessary for success. The operator should use 
for the internal hand the one the palm of which would naturally face the 
fetal breech, or the hand the fingers of which naturally flex toward the 
fetal breech. Thus in right scapula positions of the shoulder he should 
use the left hand internally, and in left scapula positions the right hand 
in the vagina. If possible, he passes two fingers through the os, as thus 
more force can be secured and there is less danger of rupturing the mem- 
branes with two than with one finger. With the external hand steadying the 
head, the two fingers in the lower uterine segment by a movement of flexion 
push the apex of the shoulder upward and toward the side of the uterus occupied 
by the breech; at the same time the external hand, already placed upon the 
head, pushes the head down into the pelvic inlet, where it is recognized and 
received by the two internal fingers and further adjusted to the inlet. For the 
version to be completed the long axis of the fetus must correspond to that 
of the uterus. In some instances the fetal breech will not readily rotate into 
the fundus even after the head occupies the pelvic inlet. In such cases it is 
advisable to withdraw the vaginal hand, the external hand still firmly holding 
the head at the inlet, and to use this hand to pushup the breech into the fundus. 
It is only at this point in the operation that the operation, strictly speaking, 
is "bipolar," namely, the forces are applied to the opposite poles of the 
fetal ellipse. The head must be held by external palpation until it engages 
or engagement can be hastened by artificial rupture of the membranes. 

In Breech Presentation. — It is often desirable at the onset of labor to convert 
a breech into a vertex presentation in order to better the prognosis for both fetus 

* Hicks: " Combined External and Internal Version," 1864. 
t "Amer. Jour, of Obstet.," vol. vi, Part I, 1873. 



992 



OBSTETRIC SURGERY. 



and mother. External version should always be tried first, and, failing in this, 
we resort to combined external and internal version. Under such circumstances 
the version is, strictly speaking, "bipolar," since force is applied to both poles 
of the fetal ellipse. Operation: The same general principles as to preparation 
and posture of the patient apply here as in cephalic version in shoulder presenta- 
tion. As in shoulder presentation, so here, there is a distinct advantage to 
the operator and the prognosis in the choice of the hand to be used internally. 
The principle to be followed here as in other varieties of version is to have 
the fetal ellipse revolve " occiput first " about the uterine cavity. Of course, it 
is just as short a distance for the head to revolve one way as the other in pelvic 
presentation. So in left sacro positions of the breech it is advantageous to 
use two fingers of the right hand in the lower uterine segment, by flexing 
these fingers to push the fetal breech to the mother's right, and thus the 
occiput will traverse the left wall of the uterus and there will be little danger 

of head extension or prolapse of the 
hands or arms. In left sacro posi- 
tions the left hand is used externally 
to push the head around the left wall 
of the uterus in conjunction with the 
efforts of the internal right hand. 
As soon as the breech has disap- 
peared from the touch of the internal 
fingers these remain quiescent until 
the apex of the shoulder can be 
reached, when it is pushed by a. 
movement of flexion with the fingers 
in the direction the breech has taken. 
After the shoulder has been passed 
on, the internal fingers at the os 
await the coming of the head, as in 
combined cephalic version in shoulder 
presentation. If after the bringing 
down of the head it is found that the 
fetal breech has not ascended so far 
as the fundus, the vaginal hand is 
withdrawn and used to push up the 
breech, the head being still held in 
place with the original external hand. 
In right sacro positions the choice of hands is reversed, as the left hand is used 
internally and the right externally. 

III. Internal Cephalic Version. — Before the introduction of internal podalic 
version internal cephalic version was frequently performed by passing the 
whole hand into the uterus, grasping the fetal head, and drawing it down into 
the os. The operation is more difficult than combined or internal podalic 
version and the maternal prognosis is not so good, although theoretically the 
fetal prognosis is better. After the introduction of podalic version the cephalic 
variety was practically abandoned, but has recently been revived. Conditions 
necessary: Complete dilatation of the os with no disproportion between the head 
and maternal parts must exist. The operation is not intended for rapid delivery. 
Operation — method of D'Outrepont: The uterus is supported with the external 
hand. The internal hand seizes the presenting shoulder and, during the intervals 
between the pains, pushes the shoulder upward and in the direction of the 




Fig. i 126. — Internal Cephalic Version 
D'Outrepont's Method. 



VERSION. 



993 



breech, until the head descends into the pelvic inlet (Fig. 1126). Method of 
Busch: The head, if on the left side, is grasped by the right hand through the 
cervix while the other hand carries up the breech ; the head is then drawn as 
far as possible into the cervix by the operator's hand, with the thumb and 
little finger upon the temples and the other three fingers over the occiput (Fig. 
1127). Vienna method: By the Vienna method the head is guided to a position 
over the os by the combined method of Hohl (q. v.) and then grasped and 
drawn into the cervix. 



(B) PODALIC VERSION. 

Combined and internal podalic versions are performed more frequently 
than all other varieties, so much so that in America the general term 
version is almost synonymous with 
internal podalic version. 

I. External podalic version is 
never used, the combined or bipolar 
and the internal methods being pre- 
ferred. 

Indications. — Podalic version is 
indicated: (1) in shoulder presenta- 
tion when cephalic version has failed 
or the conditions are unfavorable for 
its performance; (2) in cephalic pres- 
entation when the prognosis is bet- 
tered by feet-first delivery, as in con- 
tracted pelves; prolapse of the cord 
or extremities; in certain malpresen- 
tations and malpositions, such as face 
and brow presentations, and in per- 
sistent occipito- and mento-posterior 
positions at the pelvic inlet; (3) in 
certain emergencies either for the con- 
trol of hemorrhage or for rapid de- 
livery, such as placenta prsevia and 
accidental hemorrhage, eclampsia, or 
sudden death of the mother. 

II. Combined or Bipolar Podalic Version. — The method used to-day is prac- 
tically the bipolar method of internal and external manipulation of Braxton 
Hicks. I shall not enter into a comparison of the difference in the combined 
methods of Busch,* D'Outrepont,t Wright,! Hohl,$ and Hicks, || since they 
differ merely in detail, all simultaneously employing the external and internal 
hand, but discuss only Hohl's and Hicks 's methods, which limit the internal 
hand to the introduction of one or two fingers through the os. The methods 
of Busch and D'Outrepont, which required the introduction of the whole hand 
through the cervix, are to-day practically obsolete. Any method of combined 

*Scanzoni: "Lehrbuch der Geburtshulfe," 1S69, Bd. in, p. 63. 
t Op. cit., p. 65. 

t Wright: "Amer. Jour. Obstet.," vol. vi, Part I, 1873. 
§ Hohl: " Lehrbuch der Geburtshulfe," Auflage 1862, p. 784. 

ji Hicks: "Combined External and Internal Version," "Trans. London Obstet. Soc," 
vol. v, p. 230; "Amer. Jour. Obstet.," July, 1879, p. S93- 
63 




Fig. 



1 127. — Internal Cephalic 
Busch's Method. 



Version. 



■ 



994 



OBSTETRIC SURGERY. 



podalic version which necessitates the introduction of the whole hand into 
the uterus can scarcely give better results than internal podalic version. The 
priceless advantage of the method described by Hicks is that it can be per- 
formed early in labor, or even in late pregnancy, as its only requisites for 
success are (i) sufficient mobility of the fetus in the uterus^ (2) an exact 
diagnosis of the fetal presentations and position; and (3) sufficient dilatation 
of the os to allow of the passage of two fingers. 

1. In Shoulder Presentation. — Bipolar podalic version may be tried in 
cases in which external or combined cephalic have failed, or in cases of shoulder 
presentations in which it is very important to bring down a leg to control 





Fig. 1 128. — Combined or Bipolar Po- 
dalic Version. Braxton Hicks's 
Method. First Step. 



Fig. 1 129. — Combined or Bipolar Podalic Ver- 
sion. Braxton Hicks's Method. Second 

Step. 



hemorrhage, as in placenta praevia, or for purposes of subsequent rapid delivery. 
In all such cases in which the membranes are intact, or in which they have not 
long been ruptured, bipolar podalic version can be attempted without any disad- 
vantage or danger to mother or fetus; for should circumstances prevent recession 
of the shoulder, and version by this method fail, the hand can be passed into 
the uterus, provided there is sufficient dilatation, and internal podalic version 
promptly performed. Operation: Anesthesia as in combined cephalic version is 
a practical necessity. The dorsal posture of the patient upon a sufficiently 



VERSION 



995 



high table is usually to be preferred, although the lateral or exaggerated semi- 
prone can be substituted in difficult cases. (See page 940.) The internal hand 
should be the one whose fingers naturally flex toward the fetal head ; thus, in left 
scapula positions the left hand is used internally, and in right scapula positions 
the right hand. The proper hand is introduced into the vagina and two fingers 
are passed through the os. The external hand rests over the fetal breech. 
Now with the internal fingers the presenting shoulder is gently pushed upward in 
the direction of the head and at the same time somewhat toward the fundus. This 
latter movement brings the fetal abdomen in part over the os, and renders 
descent and grasping of a foot more easy. At the same time, with the external 
hand the breech is pushed down 
into the lower uterine segment to 
replace the shoulder. If this sub- 
stitution can be accomplished, the 
most available knee or foot, which 
is usually the anterior, is sought for 
by the internal fingers and hooked 
down into the vagina through the 
os. When once the knee or foot is 
caught, the external hand is trans- 
ferred from the breech, which it has 
been pushing down, to the lower 
portion of the fetal head, which it 
pushes upward and into the fundus 
uteri. The ease with which the 
operation is performed will depend, 
of course, upon the mobility of the 
fetus in the uterus, and practically 
upon the amount of liquor amnii. 
It is generally considered that pro- 
lapse of an arm renders the per- 
formance of combined podalic ver- 
sion in shoulder presentation im- 
possible. Dr. Frank P. Foster, of 
New York,* operated in such a case 
by using the prolapsed arm as an 
aid to the version. The presenta- 
tion was a shoulder and the posi- 
tion right scapula anterior with the 
left arm prolapsed into the vagina. 

With the right hand in the vagina Dr. Foster grasped the arm, and, using it as 
a kind of handle, gently pushed upward in the direction of the humerus. The 
shoulder and cephalic pole of the fetus were thus elevated, and with the index- 
finger in the cervix the breech was reached and pushed in the direction the head 
had taken until the leg was recognized and brought down. 

2. In Cephalic Presentations. — (Figs. 1128 to 1131.) The indications and 
conditions necessary for the performance of bipolar podalic version in cephalic 
presentation — namely, vertex, brow, and face — are practically the same as in 
shoulder presentation. The head must not be too firmly engaged. Operation: 
Anesthesia here is also a necessity and the dorsal posture is to be preferred in 




Fig. 1130. 
Version, 
Step. 



Combined or Bipolar Podalic 
Braxton Hicks's Method. Third 



* Foster: " On Prolapss of the Arm in Transverse Presentations,' 
Obstet.," vol. ix, p. 203. 



' Amer. Jour, of 



996 



OBSTETRIC SURGERY. 




;/ 



ordinary cases. As in shoulder presentation, a movable fetus and an exact diag- 
nosis of the presentation and position are necessary for success. It is important 
that the fetus shall revolve occiput first about the uterus. This causes the feet 
to travel about the shortest possible distance in order to reach the cervix; there 

is less danger of extended head and arms, 
and the revolution of the fetus thus is more 
readily accomplished. Hence, contrary to 
many authorities, I believe that there is a dis- 
tinct choice in the hand used internally. In 
left dorso positions the left hand should be 
used internally, and in right dorso positions 
the right hand, (i) With, the appropriate 
hand in the vagina, two fingers through the 
os, and the external hand on the breech, the 
internal fingers by a movement of flexion 
gently push the head upward and in the 
direction of the occiput, the external hand at 
the same time pushing the breech by a gentle 
sliding motion in the opposite direction. This 
is to be continued until the head has passed 
out of the reach of the internal fingers. ( 2 ) As 
the head departs from the internal fingers, if 
all goes well, the normal attitude of the fetus 
is preserved and no extension of the head or 
displacement of the arms occurs. The exter- 
nal hand now simply continues its pressure 
and forces the breech with the feet into the 
lower uterine segment, where one of the latter 
or a knee is secured by the fingers of the in- 
ternal hand. In less favorable cases, by 
reason of the uterus enveloping the fetus 
too closely, extension of the head takes place; 
it does not readily pass upward along the 
side of the uterus into the fundus, and the 
shoulder or fetal chest is felt by the internal 
fingers just over the os. In such cases one 
must treat the shoulder or chest in the same 
way as the head by gently pushing it upward 
in the same direction the head has taken. 
Care should be used in this case not to con- 
found an elbow with a knee. (See page 1002.) 
As soon as a knee or a foot is recognized it 
should be seized, and the membranes be rup- 
tured if still intact. (3) After the knee or foot 
is firmly secured by the internal fingers, the ex- 
ternal hand is transferred from the breech to 
the other side of the abdomen and placed be- 
low the head, which is by a gentle sliding motion pushed upward into the fundus, 
while at the same time the foot is drawn down through the os into the vagina. 
Some operators always bring down a knee through the os and afterward extend 
the leg in the vagina, claiming that a better grasp is to be had in the flexure 
of the knee than on the foot. I have found it much more convenient and simple 






Fig. 1131.— Half Breech Formed 
when One Leg is Brought down 
in Podalic Version. — (Leopold.) 



VERSION. 



997 



to seize the foot in the uterus, as it will be found that the foot comes first within 
reach of the internal fingers. The leg being through the os, traction should be made 
upon it until two-thirds of the thigh has passed through the os and the half breech 
is beginning to enter. This will bring the foot outside the vulva. As traction 
is thus being made upon the leg, external palpation is used to make sure 
that the head occupies the fundus. Traction on the leg until the thigh engages 
in the os, combined with external upward pressure on the head, assists in 
completing the version and preventing recession of the part engaged. When 
the long axis of the fetus corresponds to that of the uterus the version is 
completed. Whatever is subsequently done in the way of extraction 
will be quite another operation. Choice of the leg to be seized: It is generally 
stated that in combined podalic version in head presentations there is no 
choice as to which leg is seized and that it makes no difference whether it is 
the anterior or posterior which is secured. There is a principle in all varie- 
ties of internal version, namely, that the leg which is brought down always 
eventually rotates forward behind the symphysis. This rule has few exceptions. 
Hence it will be found expedient, in 
order to avoid unnecessary rotation of 
the fetus within the uterus, always to 
attempt at least to seize the anterior 
knee or foot, unless some distinct indi- 
cation to the contrary exists. There is 
practically but one exception to the rule 
of seizing the anterior foot, and that 
exception exists in flattened pelves after 
it has been definitely determined that 
more room exists on one side of the 
pelvis than the other on account of the 
greater width of the sacral ala on one 
side. In such a contingency it is de- 
sirable to bring the occiput and the wide 
biparietal diameter into the roomiest 
lateral half of the pelvis. Since, as 
stated above, the leg which is brought 
down always eventually rotates to the 
symphysis, if we desire the occiput to 
occupy a roomy left side of the pelvis 
we bring down the left foot, and the 
right if we want the occiput in the right 
half. Fig. 899 (page 708) illustrates 
the type of pelvis referred to, in which, 
as will be seen, the roomiest lateral 
half of the pelvis is the left half. It 
is not by any means always possible 
to choose a given knee or foot with 
two or three fingers only in the lower 
uterine segment, hence in cases in which 
the choice of the leg to be seized is im- 
portant in the prognosis, it is better to 

wait until spontaneous or artificial dilatation is accomplished, to pass the whole 
hand into the uterus and to select the desired leg, thus practically doing an 
internal podalic version. (Compare page 1001.) 







Fig. 1132. — Internal Podalic Version 
in Cephalic Presentation. Intro- 
duction of the internal hand into the 
uterus, and downward pressure of the 
external hand to bring the legs within 
reach of the internal hand. 



998 



OBSTETRIC SURGERY. 



III. Internal Podalic Version. — This is one of the most valuable resources in 
obstetric emergencies. It is indicated when the safety of the mother or child 
requires immediate delivery, and when the use of the forceps is contraindicated 
{e. g., in placenta praevia, puerperal eclampsia, prolapse of the cord, etc.). It 
is also indicated in various malpositions in which natural delivery or delivery 
by forceps is hazardous or impossible {e. g., in delayed first stage due to occipito- 
posterior position, or to face presentation), and in cases in which the after- 
coming head is better adapted than the fore-coming head to pass through the 
birth canal (e. g., in flattened pelvis). Internal podalic version in both cephalic 
and shoulder presentation is to-day performed so frequently that when the term 
version is used it is often, if not always, understood to mean internal version. 
Operation : The operation consists in the introduction of the whole hand into 
the uterus, seizing a foot or two feet, bringing it or them into the vagina through 
the os, and pushing the fetal head into the fundus by external manipulation 
with the external hand. Unfortunately the version by the internal metnod is 
most easy of performance, hence it is often done without first giving ex- 
ternal or combined version a trial. It should ever be borne in mind that the 
operation of internal podalic version, whether in shotilder or cephalic presenta- 
tion, is a serious operation and one 
not to be lightly undertaken; that 
there are always distinct dangers of 
injury to the maternal soft parts, even 
to the extent of rupture of the uterus ; 
that the danger of the introduction 
of septic material and air into the 
uterus and to the placental site is 
ever present; that podalic version 
once completed means the delivery 
of the fetus spontaneously or, as 
usually occurs, artificially feet first, 
and that in such delivery the mortality 
is always greater for the fetus, and the 
morbidity for the mother, than in 
most cases of spontaneous or artificial 
head-first deliveries. The fetus was 
intended by nature to pass head first 
through the pelvis. Reverse nature's 
process and the breech, a poorer 
dilator than the head, is the first to 
pass through and dilate the passages ; 
then come the dangers of arms ex- 
tended over and impacting the head ; 
extension of the head increasing the 
danger, and the delivery of the in- 
compressible head rapidly, in ten 
imperfectly dilated by the fore-coming 




Fig. i 133. — Internal Podalic Version in 
Cephalic Presentation. Grasping the 
anterior leg with the internal hand and 
upward pressure upon the anterior shoulder 
with the external hand. 



minutes at most, through passages 
breech. 

Conditions Necessary and Contraindications. — Pelvic deformity must not 
be too great, nor must it be of such a kind as to interfere with the passage of 
the after-coming head. The cervix must be completely dilated. If this is not 
the case, complete manual dilatation and paralysis should be secured as a pre- 
requisite. In rare cases incision may be necessary. There must not be tetanic 
contraction of the uterus, and it is highly desirable that the membranes should 



VERSION. 



999 



not be ruptured or should only recently have ruptured. The presence of the 
contraction ring above the fetal head or more than four inches above the sym- 
physis renders the operation extremely hazardous, owing to the danger of 
uterine rupture. If the head is impacted or firmly wedged in the pelvic inlet, 
so that much pressure is required to dislodge it, version is of course contra- 
indicated. Version should not be performed for the delivery of a very small 
or of a premature child, unless the forceps is contraindicated, for forceps 
delivery in these cases is usually easy, and if properly performed less likely to be 
fatal to the child. Internal version should not be performed for the delivery 
of a macerated or dead fetus. If the child is dead, craniotomy should be per- 
formed unless the delivery promises to be very easy and unattended by lacera- 
tion of the maternal structures. 

General Preparations. — The dorsal posture of the patient upon a high oper- 
ating table is to be preferred to the lateral, exaggerated semi-prone, knee-chest, 
and Trendelenburg pos- 
tures, in all but exceptional 
cases. In difficult versions 
in impacted shoulder pres- 
entation the Trendelen- 
burg and exaggerated semi- 
prone position will greatly 
assist our endeavors to dis- 
lodge the impacted shoul- 
der. (See page 947.) The 
bladder and rectum must 
be thoroughly emptied, 
the pubic hair removed, 
and I am accustomed to 
prepare the external geni- 
tals, adjacent parts, and 
vagina, as for a major 
gynecological procedure; 
vaginal hysterectomy, for 
example. Of course, vagi- 
nal mucus and lubrication 
are thus removed, but it 
will be found that a good 
substitute is a 1 per cent, 
solution of lysol, with 
which the vagina should 
finally be freely irrigated. 
Anesthesia is a necessity 
in internal version, as it 
is important for the ma- 
ternal and fetal prognosis 
that the greatest possible 
relaxation of the uterus be 
obtained. Theoretically, 
chloroform gives a more 
thorough uterine relaxa- 
tion than ether, but it will be found that ether, if properly given, will answer 
every purpose, and it is certainly the safer anesthetic. (Compare Anesthesia, 
page 933.) 




1 mm 



W 



Fig. i 134. — Internal Podalic Version in Left 
Scapuloposterior Position of the Shoulder. The 
right hand is used internally to grasp the feet, and the 
left externally to depress the fundus. This method is 
not recommended. 






1000 



OBSTETRIC SURGERY. 



i. In Vertex, Bregma, Brow, and Face Presentations. — The prepara- 
tions having been carefully made, here, as in other varieties of version, success 
depends upon an accurate diagnosis of the presentation and position. Our 
object in internal podalic version in cephalic presentations is to pass the whole 
hand into the uterus, seize one or two feet, bring the latter into the vagina, 
and assist the head with the external hand to pass upward and occupy the 
fundus of the uterus. 

Choice of Internal Hand. — According to many authorities, the primary 
choice of hands is not a matter of great consequence. I believe, however, the 
choice of hands to be an important factor in the prognosis; and the greater 
the operator's experience, the greater care will he exercise in this respect. That 
hand should be used internally the palm of which naturally without exaggerated 
pronation or supination faces the fetal abdomen. Thus, in left dorso positions 
— namely, left occipitoanterior and -posterior, right mento-anterior and -poste- 
rior, and right fronto-anterior and -posterior — the left hand is the one to use in- 
ternally for grasping the foot or feet, 
as this hand most naturally by the 
shortest path and with least dis- 
turbance of the fetal ellipse comes 
to the feet and readily selects one 
or both for traction. However, 
in right dorso positions — namely, in 
right occipito-anterior and -poste- 
rior, in left mento-anterior and 
-posterior, and in left fronto-ante- 
rior and -posterior — the right hand 
should be used, for the above rea- 
sons. In pelves flattened from any 
cause, and especially if the pelvic 
inclination is increased, there may 
be a decided posterior obliquity of 
the uterine axis in reference to the 
axis of the pelvic inlet, with a 
perfectly movable head. Under 
such circumstances rotation of the 
fetal back often occurs and the 
feet are found not to one side, 
but well up against the posterior 
wall of the fundus. Here, of 
course, it is immaterial which hand 
is used internally, but in the great 
majority of cases of cephalic pres- 
entation external and internal ex- 
amination will reveal the fetal dor- 
sum inclined either to the left or 
right. 

Treatment of Intact ^Membranes. 
— If internal version is to be performed when the membranes are intact, 
and it is most desirable and advantageous that they shall remain unruptured 
until the hand is introduced into the vagina, and the liquor amnii thus being 
dammed back in the uterus after the membranes are finally artificially rup- 
tured, the question is often asked, What is the treatment of the unruptured 




Fig. i 135. — Internal Podalic Version in 
Left Scapuloposterior Position of the 
Shoulder. The left hand, the palm of 
which naturally faces the fetal abdomen, is 
used internally to grasp the feet, and the 
right hand externally to depress the fundus. 
This method is to be preferred to that of 
Fig. 1 134. 



VERSION. 



1001 



membranes? Three plans have been practised by various authorities in time 
gone by: (i) One plan is to seize the foot or feet through the unruptured 
membranes and complete the version without rupturing them; (2) another is to 
pass the internal hand up between the uterine wall and membranes until oppo- 
site the feet and then rupture; (3) and the third is to rupture the membranes 
at the level of the os and introduce the hand into the amniotic cavity during 
the escape of the water. The first plan is to-day practically obsolete, and the 
passage of the hand up until opposite the feet, as in the second plan, carries 
with it unnecessary dangers of septic infection, accidental hemorrhage from 
premature placental separation, and rupture of the uterus. I have seen several 
cases of alarming ante-partum hemorrhage from this method. It is not to be 
recommended. The third method of low rupture is the safest of all and quite 
as satisfactory as any other. In this method there is no danger of accidental 
hemorrhage; the liquor amnii is quite as 
readily dammed back in the uterus by the 
wrist and forearm in the vagina; and then 
we have the great advantage of working 
entirely within the membranes from the 
internal os, they forming, so to speak, a pro- \ 

tecting glove covering the internal hand and Vi 

reducing the dangers of infection to a mini- 
mum (Fig. 645). 

Further Course of the Internal Hand. — In 
the absence of uterine contraction, the inter- 
nal hand should gradually be passed within 
the bag of membranes upward toward the 
fundus and along the lateral uterine wall, dis- 
turbing the fetal ellipse as little as possible. 
During the entire time the external hand 
must make careful counter-pressure over the 
fundus until the feet are seized. If a 
uterine contraction at any time occurs, all 
upward movements of the internal hand 
must cease and the hand lie flat against the 
uterine wall until the contraction has passed 
off. Some difficulty will usually be encoun- 
tered in passing the presenting head. This, 
as a rule, can be overcome by gently push- 
ing it toward the iliac fossa opposite the 
internal hand. In late internal podalic ver- 
sions in cephalic presentations attention 
must be paid to the condition and location 
of the contraction ring. Should one palpate 
the contraction ring projecting markedly 
toward the fetal head, — and there is difficulty, 
under deep anesthesia, of passing the hand 
by this ring, — the version should be aban- 
doned, since the conditions indicate retrac- 
tion of the body of the uterus, ascent of the 

retraction ring, and dangerous thinning of the lower uterine segment. There 
would be great danger of uterine rupture in attempting to displace the head 
upward and over such a retraction ring. 




Fig. 1 136. 



-Method of 
One Foot. 



Grasping 



I 



1002 



OBSTETRIC SURGERY. 



j 



J 




I 



Choice of Leg to Bring Down. — Shall we seize one or both feet; and, if one 
foot, the knee or foot, the anterior or posterior leg ? If both legs only are brought 
down and not one leg alone, the whole breech makes a better dilator for cervix, 
vagina, and vulva that the half breech (Fig. 1131), and hence the fetal prognosis 
is improved because a fuller dilatation of the passages diminishes the danger 
of the after-coming head and the disengagement of possibly extended arms. 
If the fetus is dead or macerated; if it is small or medium-sized; and if in the 
interest of the mother great haste is essential, the grasping of both legs will 
also be indicated. If both legs are brought down, the feet are seized. There 

are two advantages in seizing a knee and not a 
foot when one leg is brought down first: the 
knee in a normal attitude is nearer the os than 
is the foot, and, second, the flexure of the knee 
offers a convenient hold. One foot is difficult 
to grasp within the uterus without doubling 
the hand into the shape of a closed fist, and this 
occupies much space. On the other hand, the 
knees lie near the elbows, and differentiation 
with fingers whose sensation is partially lost by 
reason of uterine pressure is not always easy. 
To distinguish the knee from the elbow, one 
should recall that the knee is relatively broad, 
has not the sharp projection of the olecranon, 
and usually points toward the head; while the 
elbow is sharp and points away from the head. 
In doubt, one can follow along the extremity 
and differentiate hand from foot, or in the op- 
posite direction and distinguish shoulder from 
breech. When the knee is selected, the fore- 
finger is slipped into the fold of the popliteal 
space, the knee is drawn down through the os 
into the vagina, and the leg then extended and 
subsequent traction made upon the leg. As re- 
gards the choice of legs when one is seized, many 
authorities state that it makes no difference 
which is selected ; that the best plan is to seize 
whichever comes first and is most readily found. 
As stated elsewhere, whichever leg is seized in 
version eventually comes to the pubic angle, 
hence to avoid unnecessary torsion of the fetus 
it will be found advantageous always to select 
the anterior leg. To sum up, the plan I have 
found most successful is to seize the knee when 
one leg is to be brought down and the feet when both. I always endeavor to 
bring down the anterior leg in single-leg versions. 

Difficult Internal Version in Cephalic Presentation. — If one encounters diffi- 
culty in the rotation of the fetus, the same two expedients may be used as are 
made use of in difficult internal podalic version in shoulder presentation. The 
manceuvers constitute the so-called combined manipulations. One is by me- 
chanical means to apply greater traction on the leg than we are able to do with 
the hand; and the second is, by an arrangement of the soft fillet or sling to 
draw down on the leg or legs while we push up the head internally (Fig. 113S). 




L 



Fig 



1 137. — Method of Passing 
a Sling over a Foot Pro- 
lapsed into the Cervix or 
Vagina. 



VERSION. 



1003 



These methods are described on page 1004, under "Version in Impacted Shoulder 
Presentation." It must ever be remembered that in cephalic presentation diffi- 
cult version by the combined manceuver is usually a more dangerous procedure 
for the integrity of the uterus than is an operation of equal difficulty in shoulder 
presentation. Moreover, difficult version in a cephalic presentation is almost 
always undertaken in the interests of the fetus; namely, in malpresentations 
and malpositions; hence if the resistance to the rotation of the fetus is very 
great, we must be careful not to per- 
sist and thus run too great a risk of 
uterine rupture. 

2. In Shoulder Presentation. 
— The preparation and the general 
principles are the same as in cephalic 
presentation. 

Choice of Internal Hand. — Because 
the feet are usually within easy reach 
in the center of the uterus, the choice 
of hand is not so important as in 
cephalic presentation. In general, 
the hand should be used the palm 
of which most naturally faces the 
legs. Thus, in left scapula positions 
of the shoulder I always use the left 
hand internally to grasp the foot or 
feet, and in right scapula positions, 
the right. 

Treatment of Intact Membranes. — 
This is practically the same as in 
cephalic presentation. 

Choice of Leg to Bring Down. — 
Some operators attach little impor- 
tance to the choice between the upper 
or lower leg, and seize either foot 
indifferently. In Germany prefer- 
ence is given to the lower leg, 
and in England the followers of 
Simpson teach the doctrine of select- 
ing the leg on the side of the body 
opposite to the presenting shoulder. 
I hold that a distinct choice exists 
here, although in extreme emergency, 
when the time does not allow of a 
positive diagnosis of the position, one 
is only too glad to seize the first foot 
available. A study of the mechan- 
ism of labor in pelvic presentation will convince one of the importance of the 
fetus maintaining a dorso-anterior position. Further, in order that the fetal 
attitude may be disturbed as little as possible, it is necessary that the leg 
selected shall take the shortest road to the pubic arch. Both of these condi- 
tions are fulfilled by selecting the lower leg in scapulo-anterior positions, and 
the upper or remote leg in scapulo-posterior positions. 

Sling to the Prolapsed Arm. — In case an arm is prolapsed in the vagina or 




Fig. 113S. — Difficult Podalic Version in 
Cephalic Presentation. Combined ma- 
nipulation, consisting in upward pressure 
upon the head with the hand in the uterus, 
and downward traction with a sling at- 
tached to a prolapsed leg. 



1004 



OBSTETRIC SURGERY. 



through the vulva, there should never be any attempt at replacing it, but a 
sling should be attached to the wrist, affording thus a distinct advantage. The 
operator has thus complete control over one arm at least, and he will always 
be able to prevent this arm from becoming extended above the head and so 
delaying the extraction of the after-coming head. (Compare "The Sling.") 

Version in Impacted Shoulder Presentation. — In instances in which version is 
demanded after the membranes have been ruptured for some time and the uterus 

is closely contracted around the 
fetus, we may find much diffi- 
culty in moving the fetus, after 
the leg has been seized even, 
and with the assistance of ex- 
ternal manipulations. Three 
expedients will here usually 
prove successful, although in the 
case of a dead fetus and dan- 
gerous thinning of the lower uter- 
ine segment decapitation is the 
safer operation. First, an anes- 
thetic to the full surgical degree 
is demanded, in order to secure 
the greatest possible relaxation 
of the uterus. Second, some 
means is employed to secure 
more powerful traction on the 
leg than can be obtained with 
the internal fingers. The best 
way of making powerful trac- 
tion is by the aid of the sling 
(Figs. 1137 and 1138). Third, 
the internal hand is used not to 
draw down on the leg, but firmly 
to push up on the shoulder. The 
sling to the leg leaves ample 
room for this, and we thus bring 
two forces simultaneously into 
play on the opposite poles of 
the fetal trunk (Fig. 1 138). In 
very difficult cases the second 
leg can be brought down, a sling applied to it, and traction made on both legs 
simultaneous! v. 




::« #V 






Fig. 1 139. — The Completion of Podalic Ver- 
sion. The version is finished when the knee is 
at the vulva, and the long axes of fetus and 
uterus correspond. 



(D) PELVIC VERSION. 

Pelvic version, in which the breech is caused to present by external, com- 
bined, or internal manipulation, without a leg being brought down, is to-day 
rarely performed, being practically obsolete. The same, general principles as in 
cephalic or podalic version govern its performance. 

Prognosis. — In the 44 cases analyzed by the author one mother died from rup- 
ture of the uterus following manual dilatation and internal podalic version for 
placenta praevia. Of the children, 32, or 72.5 per cent., were delivered alive; 
7, or 15.9 per cent., were still-born; 1, or 2.27 per cent., died in the puerperium, 



PELVIOTOMY. 1005 

and in 5 there was no record of the result (compare Forceps). Forceps opera- 
tion was attempted in 6 cases prior to the version. 



XII. PELVIOTOMY. 

Symphyseotomy is so well, if not so favorably, known that the practitioner 
generally ignores the fact that this particular form of intervention is but one of 
several methods of dividing the pelvic ring. Double Ischio-pubiotomy : A few 
years after Sigault's introduction of symphyseotomy, Aitken performed an opera- 
tion for enlarging the pelvic cavity by sawing through the two rami of the ischium 
and those of the pubis on either side of the pubic bone. Double Pubiotomy : Pitois 
modified this operation by carrying the incisions through the pubic bone on both 
sides of the symphysis. Triple Pelviotomy : Finally Galbiati, the distinguished 
symphyseotomist, added ischiopubiotomy to symphyseotomy, thus dividing the 
pelvic ring in three different localities. These operations were practised as a 
variation or extension of the principle of symphyseotomy, in cases in which the 
latter operation could not sufficiently enlarge the pelvic cavity; such a state of 
affairs could hardly occur save in high degrees of pelvic contraction, ankylosis, or 
deformity, or in some condition of the symphysis in which its division is contra- 
indicated. Operations dividing the pelvic bones have been looked upon as obso- 
lete, being supplanted, since the antiseptic era, by artificial premature delivery, 
Caesarean section, etc. However, in 1892 Farabeuf revived this principle by 
recommending and practising ischiopubiotomy (unilateral) in the asymmetrical 
ankylosed pelvis. 

Unilateral Ischio-pubiotomy. — This operation, according to Farabeuf, is one 
which may be performed by any practitioner without difficulty or risk. Its 
technique is as follows: The cutaneous incision should be parallel with the 
median line and at a distance of ih inches (4 cm.) from it. The rami of the 
ischium and those of the pubis are thereby exposed sufficiently for the passage of 
a chain-saw around them. The ramus of the ischium is to be divided by the 
side of the perineum, to the right of the fourchette; the ramus of the pubis is to 
be divided a finger's-breadth to the outer side of the pubic bone. A finger should 
be kept in the vagina during the various steps which end in the division of the 
ramus of the pubis. After the pubic bone has been exposed by incision through 
the soft parts, a curved rasp is used to denude its outer aspect, lower border, and 
inner aspect of the bone, the instrument reappearing at the obturator fora- 
men. The chain-saw is passed around the bone by the aid of a blunt curved 
needle, the soft parts are pushed back, and the bone is sawed through. The 
ramus of the pubis is divided in a similar fashion, care being taken to respect the 
inguinal canal. The pectineal aponeurosis and Gimbernat's ligament are de- 
tached from the bone. The saw can be passed around the latter with very little 
preliminary denudation. No separation of the bones occurs thus far, because 
it is prevented by the obturator membrane, which must be disconnected from 
the pubic ramus. With the aid of some strong, blunt instrument the severed 
bones are now pried apart. The amount of separation obtained thereby is at 
least 1.1 inches (3 cm.). After delivery the ramus of the pubis should be wired 
together by strong metallic sutures. Ischiopubiotomy, being simply a variation 
of symphyseotomy when the latter is insufficient, comprises certain principles 
which will be considered in detail under the latter operation. 



1006 



OBSTETRIC SURGERY. 



of the joint itself is insignificant 



XIII. SYMPHYSEOTOMY. 

Symphyseotomy, or division of the ligaments which unite the two halves of 
the pubic bone, is an operation introduced into obstetrical surgery for the pur- 
pose of enlarging the pelvic inlet in dystocia arising from disproportion between 
the pelvis and the fetal head. It is quite radical as a piece of operative interven- 
tion; for despite the apparent simplicity of the operation proper, it may be re- 
garded as a crucial example of work. 

Indications. — Symphyseotomy may be regarded as an independent pro- 
cedure, or as a mere accessory to version, high forceps extraction, etc. 
Broadly speaking, it is a method for enlarging the pelvic cavity, and has 
many uses in theory which cannot be realized in practice. Chrobak* 
states that there is hardly an obstetric operation in which symphyse- 
otomy might not be employed as an adjuvant. The operation of division 

in its consequences, and the real com- 
plication lies in the injuries neces- 
sarily inflicted upon the soft parts. 
Hence symphyseotomy as an adju- 
vant to other obstetric operations 
must necessarily add to the risk 
already present. The indications 
and contraindications for symphy- 
seotomy necessarily vary with the 
point of view of the operator. The 
intervention is ostensibly to save 
the child without thereby imperiling 
the life of the mother. The Italian 
symphyseotomists, Morisani and 
Novi, do not look upon premature 
delivery, Caesarean section, and 
symphyseotomy as competitive but 
as entirely distinct procedures, each 
having its own special indications 
and contraindications. It is essential for the success of symphyseotomy that the 
pelvis be not too small for the expulsion of the child, for the subsequent application 
of the forceps must add greatly to the risk for both mother and child. It is also 
essential that the child be able to come into the world alive. Symphyseotomy is in- 
dicated if the conjugate is between 3.46 inches (8.8 cm.) and 2.64 inches (6.7 cm.). 
If this condition is insisted upon, the results of intervention are seen to be excel- 
lent. It is, however, regarded as an error to make the indication for symphyseo- 
tomy depend wholly upon the dimensions of the conjugate, as some account must 
be taken of the shape of the pelvis as a whole. Symphyseotomy is especially 
indicated in certain types of pelvic deformity, such as the funnel-shaped pelvis, 
sacro-coccygeal ankylosis, etc. In the justo-minor pelvis the operation is indicated 
without too implicit adherence to the size of the conjugate. Other indications 
for symphyseotomy are found in normal pelves with excessive size of fetal head, 
or in the presence of deformities. Neugebauer, who has doubtless devoted 
more time to the study of symphyseotomy than has any other individual, with the 

* Cited by Neugebauer, p. 197. 




Fig. 1 140. — Transverse Section of a Pelvis 
Just below the Pelvic Inlet, Mounted 
upon a Scaled Board to Illustrate Sym- 
physeotomy. 



SYMPHYSEOTOMY. 



1007 



possible exception of Morisani, states that the operation possesses a strict indica- 
tion, standing midway between artificial premature delivery and Csesarean sec- 
tion, with the former of which it may also be combined to save the life of the 
child. My experience in six cases of flattened and generally contracted pelves 
does not lead me to look with favor upon the operation. I am accustomed to 
consider the induction of premature labor and Csesarean section, and in special 
cases even embryotomy, as competitive with symphyseotomy. 

Morbidity. — Rubinrot's analysis teaches us that the operation of symphyseot- 
omy abounds in accidents. The number of post-operative complications is not 
less formidable. Shock occurs but rarely, but septic accidents are present in 
not less than 30 per cent., this proportion including mild as well as severe forms. 
There were to deaths from sepsis in 136 operations. Simple suppuration of the 
symphyseotomy wound occurred in about 10 per cent, of all cases, and cedema of 
the vulva in nearly the same proportion. Of the more unusual post-operative 
complications may be mentioned hematoma, abscess, stitch-abscess, fistula, per- 
manent separation of the pubic bones, lymphangitis, cystitis, incontinence of 
urine, paresis of the bladder, urin- 
ary fistula, bedsores in various locali- 
ties, infectious myelitis, neuralgias, 
and arthritis or other disorders of 
the sacro-iliac synchondrosis. In 
addition to the foregoing, a more 
remote series of post-operative acci- 
dents should be mentioned, the pres- 
ence of which is apparent for months 
after the operation; namely, dis- 
turbance of the gait, which is due 
to permanent separation of the 
symphysis, sacro-iliac disease, etc., 
bony sequestra, urinary inconti- 
nence and fistulae, vesical paresis, 
cystitis, and sepsis. Sepsis, the 
most redoubtable post-operative 
complication, appears to be con- 
nected especially with hemorrhage, 

whether due to the intervention itself or to uterine inertia, and with lacera- 
tions of the parturient canal, independent of coincident hemorrhage. In other 
cases no cause for sepsis is apparent. It has been claimed that sepsis after sym- 
physeotomy is especially favored by the jagged, uneven character of the opera- 
tion-wound, which latter is in marked contrast with the clean-cut incisions of 
the Csesarean section. More or less stormy convalescence followed all of my six 
cases of symphyseotomy. 

Mortality. — According to Rubinrot's analysis of 136 cases of symphyseotomy 
from 1896 to 1898, the combined maternal mortality was in round numbers 11 
per cent. Fifteen of the women died; two directly from the operation itself 
and thirteen from post-operative complications (sepsis). This percentage is in 
harmony with that obtained by Morisani for 241 miscellaneous operations per- 
formed before 1894, and by Neugebauer in his analysis of 278 cases. In regard 
to the infantile mortality, Rubinrot records 19 deaths in 136 operations, or nearly 
14 per cent. These figures are higher than those of Morisani, who places the in- 
fantile mortality at 12 per cent. This contrast is somewhat paradoxical, as 




Fig. 1 141. — Asymmetric Separation at the 
Pubic and Sacro-iliac Joints in Sym- 
physeotomy. 



1008 



OBSTETRIC SURGERY. 



Rubinrot's statistics refer to purely modern operations, while Morisani deals 
with all the cases since the first introduction of the operation. The infan- 
tile mortality appears to be due to a variety of affections and by no means neces- 
sarily to the operation. A certain number of deaths are due to attempts at 
forceps extraction before the performance of symphyseotomy, as shown by the 
presence of meningeal hemorrhage, fracture of the skull, etc., found at autopsy. 
Some of the deaths are such as are inevitable in ordinary labor, e. g., from pro- 
lapse of the cord, eclampsia of the mother, etc. Generally speaking, the infan- 
tile mortality is rendered high by reason of the prolonged sojourn of the child in 
the maternal passages, the use of anesthetics, shock, etc., — all of which condi- 
tions tend naturally to favor still-birth, apparent death, asphyxia, etc. A very 
large proportion of children delivered by symphyseotomy require reanimation. 



OPERATION. 

At the present time the operative technique is practically made up of three 
distinct methods, each of which is upheld by the operators of a particular nation- 
ality. Thus we have (i) the French or open method as performed by Pinard and 
his followers; (2) the American or 
subcutaneous method; and, finally, 
(3) the suprapubic method of Morisani 





Fig. 



1 142. — The Italian or Suprapubic 
Method of Operation. 



Fig. 



1 143. — The French or Open 
Method of Operation. 



and his pupils. All the French operations from 1896 to 1898 inclusive were done 
in the classical manner prescribed by Pinard and Farabeuf save those of 
Porak, who employs a method of his own. The French method was also 
employed in most of the operations outside of France. Morisani's method, 
which prevails in Italy, was occasionally employed in other countries, notably 
in America. Several Americans have operated by the subcutaneous method, 
while Franck in Germany and Lauro in Italy have devised modifications of 
symphyseotomy which go by their names. 

Italian or Suprapubic Method (Fig. 1 142). —The original method employed 
by Morisani, otherwise known as the Italian or suprapubic operation, is as fol- 
lows: A transverse incision 1.18 inches (3 cm.) long is made 0.39 inch (1 cm.) 



SYMPHYSEOTOMY. 1009 

above the pubis with the design of exposing the upper margin of the bone. The 
Galbiati knife is then passed behind the symphysis, as far as its lower border, and 
with a stroke of the instrument from behind upward and from below upward, the 
symphysis is divided. Morisani then waits for spontaneous expulsion, and if this 
is not forthcoming the forceps is applied. The cutaneous incision is then re- 
paired and an immovable dressing of plaster-of- Paris or silica is applied about the 
pelvis. Novi's method is practically the same, save that he uses a bistoury in- 
stead of Galbiati 's knife. He applies after the operation a simple spica bandage, 
not reinforced in any manner. A special symphyseotome has been devised by 
Spinelli, which is manufactured in three sizes. In order to use this instrument 
the suprapubic incision does not suffice and the symphysis must be laid bare. 
Morisani sometimes employs a bistoury in place of Galbiati 's knife. He appears to 
content himself with a simple roller bandage to secure the apposition of the pelvic 
bones. The Italian method as practised by Morisani and Novi is peculiar in that 
the symphysis is divided from behind forward and from below upward, and that 
no attention is given to the insertion of the recti, or to the clitoris and its vessels. 



^.\~ >: '* 







^Ssk 



Fig. i 144. — Subcutaneous or Ayers's Method of Operation. 

The chief care lies in the dissection of the retropubic tissue to make a passage! for 
the knife. Charpentier (quoted by Neugebauer) w T as much impressed by 'the 
singular unanimity of the Italian operators as to technique. 

French or Open Method (Fig. 1143). — Pinard's method, otherwise known 
as the French or open operation, is as follows: The mons veneris is shaved, 
and it is regarded as an essential step to make the incision exactly in the middle 
line. The skin and subcutaneous tissues are divided, the incision being, as a 
rule, 3.15 to 3.9 inches (8 to 10 cm.) in length, extending from above the pubis to 
just above the clitoris, deviating a little from the middle line in order to avoid 
wounding the vessels of the clitoris. The insertion of the recti is divided in the 
upper angle of the wound, so that the finger may enter the prevesical space and 
protect the bladder. The symphysis is then divided with a few strokes of the 
knife from above downward and from before backward. If the separation of the 
pubic bones is insufficient, Pinard has his assistants enlarge the breach by ap- 
propriate pressure upon the lower extremities. The ligamentous mass beneath 
the symphysis is divided last of all. Before waiting for the expulsion of the 
64 




1010 OBSTETRIC SURGERY. 

child, the symphysis is carefully examined to see if detachment is nearly 
complete. If convinced that the sacro-iliac articulation will permit sufficient 
separation of the pubic bones, Pinard immediately applies a temporary dress- 
ing to the cutaneous wound and leaves to the patient the task of expelling the 
fetus. In the open method some operators insert periosteal sutures into the 
pubic bones before closing the cutaneous wound, and one accoucheur, Fieux, 
of Bordeaux, regards this periosteal suture as quite sufficient for immobiliz- 
ing the pelvis. Others employ mechanical devices to retain the pelvic bones 
in apposition. 

Subcutaneous or Ayers's Method (Fig. 1144)- — The subcutaneous, which is 
beginning to be styled the Avers or American method, is performed as follows:* 

If possible, the cervix must be fully dilated; 
the urethra and bladder are to be held to 
one side with a sound. The initial incision 
must be made a little above the subpubic 
arch and under the elevated clitoris. The 
left index-finger is introduced within the 
vagina and held against the posterior 
aspect of the joint. A narrow tenotomy 
knife is then passed up to a point within 
:■- half an inch of the summit of the joint 

„ ~TT~ "d^ beneath the overlying soft tissues. A 

Fig. 1 145. — Mechanical Brace for . . J & . , . , 

Holding the Joint after Sym- probe-pointed bistoury is then substituted 

physeotomy. for the tenotome and carried to the top of 

the joint, where it meets the index-finger. 
It is then carried downward through the joint until the latter is felt by the 
index-finger behind to give way. An assistant now presses a small gauze 
compress against the incision beneath the clitoris. If possible, the child is 
then delivered with the forceps. When pressure is made upon the pubic bones, 
the bladder must be held to one side. A small piece of gauze is next forced into 
the wound while another strip is left in the cervix. The operator must refrain 
from immediate repair of the cervix or perineum if the latter is torn. A soft- 
rubber retention catheter is left in the bladder until the power of voluntary mic- 
turition returns. The vulva is dressed with gauze and the pelvis strapped with 
adhesive strips. All the gauze is removed in thirty-six hours and the vulva and 
vagina are irrigated twice daily, the vulva being carefully dressed between 
times (Fig. 1145). 



XIV. EMBRYOTOMY IN GENERAL. 

Much ambiguity has arisen from the defective terminology of the mutilating 
operations. There is not a word in general use to designate collectively all these 
forms of intervention. Embryulcia, a word possessing this general significance, 
is used by a few only. Embryotomy, which literally means mutilation of any 
portion of the fetus, does not, with most authors, include operations upon the 
skull, which are comprised indifferently under the terms craniotomy and perfora- 
tion. In this narrow sense embryotomy comprises the operations of decapita- 
tion, cleidotomy, eventration, amputation, etc. The absence of a general des- 

*Ayers: "The Pubic Symphysis in Parturition," " Amer. Jour, of Obstetrics and Dis. 
of Women and Children," July, 1897. 



EMBRYOTOMY IN GENERAL. 1011 

ignation to include all these operations has led to the omission by many writers 
of a general section upon embryotomy in the wider sense — its indications, fre- 
quency, prognosis, etc. 

Definition. — Embryotomy comprises all operations upon the fetus which 
have for their object a sufficient reduction in size to make extraction possible 
by the natural passages. 

Varieties. — Embryotomy includes all degrees of mutilation, from simple acts 
like cleidotomy and rachidotomy to complete morcellation of the fetus. It is per- 
formed upon both the dead and the living child, and by reason of the feticide in- 
volved in the latter case, the indications naturally diverge widely according to 
the state of the child and the point of view of the operator, since feticide is justifi- 
able only when the mother's life would otherwise be sacrificed. 

Embryotomy in general, irrespective of the state of the fetus, comprises the 
following operations: (i) Perforation of the skull. (2) Perforation of the 
spine, or rachidotomy. (3) Crushing or comminution of the bones of the 
skull — cranioclasis, cephalotripsy, basiotripsy. (4) Separation of the fetal head 
from the body — decapitation. (5) Opening of the thoracic and abdominal 
cavities, and removing the whole or a part of their contents — evisceration. (6) 
Amputation of extremities. (7) Division of one or both clavicles — cleidotomy. 
(8) Division of the spine, or spondylotomy. 

Frequency. — Embryotomy is the oldest of all the methods of intervention in 
difficult labors. Version, known during the classic period, subsequently became 
a lost art until revived in the sixteenth century. With the gradual introduction 
of version and the forceps the field of embryotomy became much restricted, 
and it came to be regarded almost as a resource of the unskilful. Early in 
the nineteenth century a few obstetricians expressed themselves in favor of doing 
away entirely with the operation as having no legitimate field. Nevertheless it 
holds a secure position to-day as regards its employment upon the dead fetus. 
The explanation of its permanency is found it its comparative innocuousness. 
Whereas the maternal mortality was once very high, it is at present the reverse. 
The reasons for this are to be found in improvement in fixing the indications, 
a proper technique, and asepsis and antisepsis. During the past fifteen years 
I have had exceptional opportunities to test every variety of embryotomy upon 
the dead fetus in the Bellevue Hospital maternity service. To this service 
are brought every year cases of neglected prolapsed cord, impacted shoulder 
presentation, hydrocephalus, persistent occipito-posterior positions, persistent 
mento-posterior positions, monsters, eclampsia, and pelvic contraction, which 
have been abandoned by midwives and physicians. It is from this extended 
clinical experience in the operating room, and not from laboratory or theoretical 
deductions, that I can speak of the comparative innocuousness of embryotomy, 
when properly performed and when the pelvis is not absolutely contracted. 
In the forties it was customary at the Dublin Rotunda Hospital to end about 
one labor in 100 by embryotomy. In hospital practice in Germany in the 
seventies and eighties there was one embryotomy in every 300 to 500 labors; 
while in private practice the proportion was about 1:1500. In 2200 hospital 
cases of confinement I find a record of six embryotomies. The indications 
were as follows: Deformed pelves, 2; hydrocephalus, 2; albuminuria, 1; epi- 
lepsy, 1. All the operations were examples of craniotomy. The maternal 
mortality was o per cent. 

Indications. — Embryotomy is indicated to-day in but two conditions. 
First, in all instances in which the fetus is dead and delivery of the unmutilated 
fetus would increase the danger for the mother. Second, upon the living fetus 



1012 OBSTETRIC SURGERY. 

in obstructed labor due to monstrosity; and in exceptional cases in which the 
mother's condition, from hemorrhage, repeated attempts at delivery, sepsis, 
or shock, is such as to render embryotomy by far the safer operation. 

Although modern obstetrics demands that embryotomy upon the living 
fetus shall, with the two above exceptions, never be performed, still two cir- 
cumstances may greatly embarrass the physician in the performance of what 
is clearlv his duty. One is the refusal of the mother and her family to accept 
Caesarean section in the presence of the relative indication, and the other is the 
varied conditions of environment under which the physician and patient are 
often placed. In the city or town a physician can refuse to perform embry- 
otomy upon a living fetus, as there are always competent practitioners at hand 
to whom the case can be transferred. In the sparsely settled country districts 
the physician is occasionally brought face to face with an obstetric complica- 
tion which demands an immediate operation in order to save the mother's life. 
I know of several such cases. One was in the mountains of northern Xew York, 
in which, during a three-day blizzard, a physician was unable to secure assist- 
ance in a case of maternal dystocia from a generally contracted pelvis, and 
was compelled to do an embryotomy to save the life of the mother. Who can 
say that embryotomy under such circumstances was criminal? This same 
case was subsequently, in her second pregnancy, sent to me in Xew York, and 
I delivered her of a living child. Some practitioners who repudiate the opera- 
tion of embryotomy propose that one shall wait for the fetus to die from birth- 
pressure, in order that the operation can be performed without compunction. 
This is a hazardous and possibly a fatal concession. For therapeutic feticide 
see page 956. 

Embryotomy upon the Dead Fetus. — Embryotomy upon the dead fetus is de- 
manded when, the absolute indication for Caesarean section being absent, the 
extraction of the fetus, undiminished in size, would increase the dangers to the 
mother. 

1. This indication includes moderate degrees of pelvic contraction, malpres- 
entations and malpositions, deformities of the fetus, and slight obstruction in 
the soft parts. 

2. In markedly contracted pelves, with a transverse diameter at the inlet of 
at least 3 inches and a conjugata vera but little under 2% inches, embryotomy 
will be indicated. 

3. In instances in which the conjugata vera is much under 2% inches, when 
labor is obstructed by a fixed pelvic tumor, an extensive exostosis, or an ad- 
vanced cancer of the cervix, celiotomy is to be preferred, whether the fetus is 
dead or alive. 

4. When the mother's condition demands rapid delivery, and the absolute 
indication for Caesarean section is absent. 

Embryotomy upon the Living Fetus. — 1. Embryotomy upon the living fetus 
is indicated during labor in certain rare instances, when the condition of the 
mother, as shown by the temperature, pulse, dangerous thinning of the lower 
uterine segment, whether from repeated unsuccessful attempts at delivery or 
from prolonged labor, would render embryotomy by far the safer operation. 

2. In obstructed labor due to monstrosities. 



PERFORATION. 



1013 



XV. PERFORATION. 

Definition. — Perforation consists in opening the fetal skull, incising the 
meninges and brain in various directions, and removing the latter by irrigation. 
Perforation of the fetal pelvis through the anus is occasionally performed. 

Indications. — (See Embryotomy, page ioio.) 

Operation. — In most cases, if only for ethical reasons, an anesthetic should be 
given. The patient should, of course, not be allowed to see the child. The 
bladder and rectum should be emptied and the vagina properly cleansed with 
lysol or creolin. The patient should be in the lithotomy position with the hips 
drawn well over the edge of a table. The operator should now make a careful ex- 
amination in order to confirm the necessity for the operation. Three types 
of perforator are in use: namely, the scissors (Fig. 1146); the screw with the 
hidden knife (Fig. 1147); and the trephine perforator (Fig. 1148). In an 
emergency almost any cutting instrument can be used; thus, twice in con- 
sultation I have opened the skull without a classical perforator, once using 
an ordinary pair of scissors, and again a scapel. Before perforating, 
especially in high positions of the presenting part, the head should be 
firmly fixed. This is done either by suprapubic pressure or by fixation with 




Fig. i 146. — Smellie's Scissors Perforator. 



a strong volsella forceps. I prefer the latter (Fig. 1149). A principle in perfora- 
tion too often neglected and misrepresented in many works on obstetrics is the 
proper location of the opening into the skull. Our aim should always be so 
to locate this opening that subsequent traction with the cranioclast (cranio- 
traction) will imitate the natural mechanism of labor. I have records of a 
number of cases in which craniotraction has been made with the cranioclast 
applied over the forehead and face in vertex presentation, thus extending the 
head and causing impaction even after perforation; and over the forehead and 
sinciput in face presentation, thus flexing a greater diameter into the birth 
canal; and over the occiput in head-last cases, producing the same result. In 
all instances care must be taken to introduce the perforator deep enough into 
the skull thoroughly to break up the base of the brain and the medulla, for 
possibly a mistaken diagnosis may result in the extraction of a mutilated child 
making attempts at respiration, than which no greater horror exists in mid- 
wifery. The fetal scalp being seized by a volsella forceps and the head drawn 
downward into the pelvis as far as possible, an assistant grasps the head through 
the abdominal walls and fixes it in the pelvic inlet. The fingers of the left hand 
are carried up behind the symphysis and their palmar surfaces guide the intro- 
duction and subsequent movements of the perforator, which is inserted with 



1014 



OBSTETRIC SURGERY. 






the right hand and carried slowly and cautiously by a twisting or boring move- 
ment through the fetal skull. A suture or fontanelle may be utilized, but it is 
better, except in simple cases, to make the opening in one of the cranial bones, 
since in the latter case it is not so likely to become closed and 
difficult to find again. Every care should be taken that the 
instrument does not slip and bury itself in the maternal 
tissues. After the perforator has entered the skull as far as 
the shoulders of the instrument it should be twisted about 
several times in order to enlarge the opening. The blades 
may also be separated in different directions for the same 
purpose. It is then carried into the skull and twisted in 
every direction in order to break up the brain and facil- 
itate its removal. If the trephine perforator is used, it is 
held against the skull by the fingers of the left hand, the right 
hand steadying the shank of the instrument. The crank is 
turned by an assistant. Whatever instrument is used, care 
should be taken to remove with the forceps all spiculae of bone, 
and the scalp should, if possible, be made to cover the edges 
of the opening in order to protect the maternal tissues. The 
cranial contents are then washed out as far as possible by 
means of a flexible tube or catheter attached to a syringe. 
The ordinary fountain syringe will be found useful. An anti- 
septic solution should be used, and in the case of a putrid fetus 
the vagina should be frequently douched during the whole 
operation. If perforation and evacuation of the cranial con- 
tents do not reduce the size of the fetal head sufficiently to 
permit safe delivery, it may be necessary to resort to the addi- 
tional operation of cranioclasm or craniotripsy (pages 1016 and 
1021). 

Pelvic Presentation. — Perforation may occasionally, in 
contracted pelves and with monsters, be applied with advan- 
tage to the breech if it fails to descend, and traction with the 
forceps, fillet, blunt hook, or upon a prolapsed leg is impossible 
or dangerous. An opening is made by way of the anus through 
the fetal pelvis and the abdominal contents are " churned up " 
and removed by irrigation (Fig. 1157). 

After-coming Head (Fig. 1156). — Three sites for perfor- 
ation are proposed by different authorities, namely, the posterior lateral fon- 
tanelle behind the ear, the occipital bone, and the floor and roof of the mouth 
through the hard palate. Many lives have been sacrificed by unskilful and pro- 



Fig. 1 147. — The 
Screw and 
Hidden Knife 
Perforator. 




Fig. 1 148. — The Trephine Perforator. 

longed attempts to perforate and extract after opening the brain in the first two 
localities, since extension of the head results, and the obstruction is often thus 
increased instead of diminished. In most cases the after-coming head should be 



RACHIDOTOMY. 1015 

perforated through the floor and roof of the mouth, then through the hard palate 
into the brain. The head can then be extracted by flexing it. In those very rare 
cases in which the chin rides up over the symphysis and cannot be gotten at, 
the head must be delivered by extension after perforation through the occipital 
bone. 

Vertex Presentation (Figs. 1153, 1155). — Both in occipitoanterior and 
-posterior positions it is best to perforate toward the occipital end of the head- 
lever, so that subsequent traction will flex rather than extend the head. If 
cutting instruments are used, I have found that it makes little difference whether 
a suture, fontanelle, or solid bone is selected for perforation; if the trephine is 
used, a bone, preferably the posterior portion of a parietal, is selected. 




Fig i 149. — Perforation of the Fetal Skull. 

Bregma Presentation. — It is best to return the head to its natural condition 
of flexion, or if this is impossible to perforate as near the occipital bone as pos- 
sible (Fig. 1 153). 

Brow Presentation. — If the brow cannot be converted into a vertex and 
perforated accordingly, it should, if possible, be changed into a face. If impac- 
tion persists, the perforation should be made at the junction of the nasal and 
frontal bones. 

Face Presentation (Fig. 1154). — Perforation at the root of the nose 
through the frontal bone gives the best results for subsequent craniotraction. 



XVI. RACHIDOTOMY. 

This operation consists in making a slight opening in the vertebral canal. 
The operation was proposed by Van Heuvel in 1848, but was not carried out until 
twenty years later by Tarnier. Rachidotomy is employed only when a hydro- 
cephalic fetus presents by the breech with retention of the head. The operation 
has been used to some extent by Tarnier and his pupils. Failure can occur only 
through a disorganized state of the spinal column as a result of excessive trac- 
tion. 

Technique. — An incision is made down to the middle of the vertebral column. 
A sound provided with a mandril is then forced through the vertebras and thrust 
into the spinal canal from below upward till it reaches the cranial cavity, when 
the liquid is allowed to drain away. 



1016 



OBSTETRIC SURGERY. 



XVII. CRANIOCLASIS. CRANIOTRACTION. 

Definition. — Cranioclasis signifies the crushing or comminuting of the bones 
of the skull within the scalp and without removing them. The operation is per- 
formed with an instrument known as a cranioclast, of which Karl Braun's is 
to-day the most perfect type. Others are Kehrer's, Simpson's, and Auvard's. 
The cranioclast is not only a crusher but a tractor; thus, when the fetal skull is 
securely seized by the two blades of the instrument it serves as a most convenient 
handle to extract the head and fetal body. To-day perforation and cranio- 
clasis are usually immediately followed by extraction, with the cranioclast as a 
tractor. The procedure then becomes craniotraction. 

Indications, — (See Embryotomy, page ioio.) 

Necessary Conditions. — (i) The pelvis must not be so greatly contracted that 
the fetal trunk cannot pass. A conjugata vera of over 27 inches (6.5 cm.") is 
necessary at full term. I believe it is generally conceded that cranioclasis 
and extraction through a pelvis represented by a conjugata vera of 2j inches 
(6.5 cm.) or under is equally as dangerous as Cesarean section. (2) In difficult 
trunk extractions the operator should never neglect to do, in addition, a clei- 
dotomy — an operation much neglected in these cases. 




Fig. iiio. — Braux's Cranioclast. 



Operation. — Instruments. — The original cranioclast, the device of Sir James 
Y. Simpson, was an evolution of the ancient craniotomy forceps and was in- 
tended by him to replace the cephalotribe. (Seepage 1 01 6.) It was proposed with 
this instrument, the solid blade of which was introduced into the perforated skull 
and the fenestrated blade upon the anterior portion of the skull, to wrench of! the 
bones of the calvarium. different portions being successively seized, and subse- 
quently to use the instrument as a tractor to deliver the remainder of the skull. 
Braun's cranioclast is intended to act primarily as a tractor and never as a bone 
forceps to break up and remove the vault of the skull. The instrument as sup- 
plied to-day by the makers consists of an exaggerated bone forceps made entirely 
of metal with a cephalic curve to the blades and the shanks and handle so long 
that the lock is outside the vulva even when the instrument is introduced high up 
(Fig. 1150). A hand-screw at the end of the handles aids compression. The 
blades, as in the Simpson's cranioclast, consist of a larger or outer blade, fen- 
estrated and grooved, which goes on the outer surface of the head over the scalp, 
and a smaller or inner blade, solid and supplied with ridges which fit into the 
grooves upon the opposite or outer blade. Although Braun's cranioclast pri- 
marily was intended as a tractor alone, still I have found it most valuable as com- 
puter of the bones of the calvarium by applying the instrument successively 
over different portions of the perforated skull and crushing the bones underneath 



CRAXIOCLASIS. CRAXIOTRACTIOX. 1017 

the scalp without attempting to remove the fragments, but bringing all away 
when the instrument is used, as a tractor. The term " cranioclast " as 
applied to the Braun instrument is a misnomer, and the term craniotractor, 
as proposed by Munde, of New York, as a substitute for cranioclast, is more 
accurate. 

Application. — The application of the cranioclast is not difficult. Unfortu- 
nately, for some reason the instrument is always made for application upon the 
right side of the pelvis, and for proper application upon the left side — the most 
frequent operation — the instrument must be reversed, with the button-lock down- 
ward. This has caused much confusion to the novice and beginner, and many 
applications of the instrument over the face, when a vertex application would 
have rendered the extraction much easier. After perforation and the washing 
away of the brain, if the head is movable the scalp is seized with strong volsella 




Fig. 

Cranioclast. — (Author's case.) 



forceps and held by an assistant. The operator then introduces two fingers of 
the left hand to the margin of the opening in the fetal skull, and with the right 
hand he grasps the inner or solid blade of the cranioclast like the blade of a 
forceps and introduces it along the fingers of the left hand as a guide into 
the opening in the skull. The handle is then held by an assistant. Now if the por- 
tion to be seized is along the left side of the pelvis, the outer or fenestrated blade 
is seized like the blade of a forceps with the left hand, the right hand is passed into 
the vagina, and the fenestrated blade is then introduced along the fingers of the 
right hand between the fetal skull and the wall of the parturient canal, care being 
taken not to include the cervix, an accident of not rare occurrence. In application 
in the left half of the pelvis the fenestrated blade must be introduced under the 
solid blade, so that the lock looks downward. The handles are now taken one in 



1018 OBSTETRIC SURGERY. 

each hand and the lock is adjusted and compression is made with the screw on the 
handle, care being taken that none of the maternal parts are included in the 
instrument and that the solid blade is well sunken in the cavity of the skull. 
Rotation of the presenting part with the cranioclast is a subject still in dispute. 
A twisting corkscrew-like motion with the instrument, as recommended by some 
operators, I have found unnecessary and dangerous, since spiculae of bone do 
occasionally in difficult cases perforate the skull, and these readily lacerate the 
adjacent maternal soft parts, and the operator is not always able to detect these 
perforations of the scalp. Rotation with the instrument, however, in order to 
bring the vertex or chin anteriorly is permissible and advisable, as in forceps 
operations. In ordinary cases reapplication of the instrument and comminution 
of the bones will not be found necessary. Traction is now cautiously made in 
the axis of that portion of the pelvis in which the head or breech lies, and if no 
slipping of the instrument occurs, the amount of traction is gradually increased 
so as to cause the perforated skull to mold itself to the shape of the pelvis, and 




Fig. i 152. — Depression in the Right Parietal Bone, Caused by Extraction with 
Braun's Cranioclast. — {Author's collection of fetal skulls.) 

to bring the cranioclast away from the side of the parturient tract into the 
middle of the pelvis. 

Left Vertex Positions. — The cranioclast should be applied so as to include 
the occipital bone (Fig. 1153). 

Right Vertex Positions. — As in left positions, the best result is obtained 
by application over the occipital bone. 

Bregma Presentation.— The best results are obtained by grasping the 
occipital end of the head-lever and if necessary rotating the occiput with 
the cranioclast to the front of the pelvic outlet (Fig. 1153). 

Brow Presentation. — If the brow cannot be converted into a vertex, the 
cranioclast is applied as in face presentation (Fig. 1154). 

Face Presentation.— The solid blade is passed into the skull through 
an opening in the frontal bone at the root of the nose, and the fenes- 
trated blade is made to include the lower jaw (Fig. 1154). The other two 
sites of application— namely, the sides of the head and the occipital region- 
are always, if possible, to be avoided. (See Perforation, page 1013.) 

After-coming Head.— Application of the solid blade through a perforation 



CRANIOCLASIS. CRANIOTRACTION. 



1019 





Fig. i 153. — Application and Use of the 
Cranioclast in a Left Occipito-pos- 
terior Position of the Vertex. 



Fig. 1 154. — Application and Use of the 
Cranioclast in a Right Mento-pos- 
terior Position of the Face. 




Fig. 1155. — Application and Use of the 
Cranioclast in a Persistent Occipi- 
to-posterior Position. 



fcx. 




Fig. 1 156. — Application and Use of the 
Cranioclast in Case of an After- 
coming Head. t.-^ 




^ 



^!~ 



"V 



S5 



Fig. i 157. — Cranioclast Ap- Fig. 1158. — Application of the Cranioclast to the 
plied to the Breech, in Left Decapitated Head in Utero. 

Sacro-anterior Position. 



1020 OBSTETRIC SURGERY. 

passing up through the floor and roof of the mouth (hard palate) and the fen- 
estrated blade over the face will give the best prognosis, as flexion of the head is 
thereby kept up (Fig. 1156). In exceptional cases in which the chin rides up 
over the symphysis, the occipital application and delivery of the head by ex- 
tension may become necessary. 

Breech Presentation. — The solid blade is passed into the anus and the fen- 
estrated blade is applied over the sacrum (Fig. 1157). 

Persistent or Permanent Occipito-posterior Position (Fig. 1155). — Our 
aim should be to secure a firm hold with the instrument over the occipital bone in 
order to exaggerate, if possible, the existing flexion of the head. The solid blade 
enters the skull at or near the small fontanelle, and the fenestrated blade, if pos- 
sible, is adjusted over the center of the occipital bone, which latter, of course, is in 
the hollow of the sacrum. In difficult cases an application made to the side of the 
head over a limb of the lambdoidal suture will be found necessary on account of 
the difficulty in applying the instrument in the sacral hollow over a tightly fit- 
ting head. Less injury to the maternal soft parts will result if we can gradually 
with our downward traction rotate the occiput into an anterior position. This 
rotation of the head with the cranioclast is, under such circumstances, not only 
justifiable but advisable, as by so doing a mechanism of labor much more favor- 
able for the maternal prognosis is obtained. Great caution should be exer- 
cised, should it be found necessary, after failure of anterior rotation, to deliver 
with the occiput to the rear. This with full-sized heads should never be at- 
tempted until after the head has been well elongated with the cranioclast, and, if 
thought necessary, comminuted as well (Fig. 1151). 

Persistent Mento-posterior Position (Fig. 1154). — No matter how great 
the temptation to apply the cranioclast over the forehead, this should always be 
avoided in face presentation, and the instrument applied to the chin end of the 
presenting lever. This can be accomplished by passing the solid blade into an 
opening at the root of the nose, and applying the fenestrated blade so as to include 
the lower jaw (Fig. 1154). This, as in permanent occipito-posterior position, 
necessitates the adjustment of the fenestrated blade in the hollow of the sacrum, a 
manceuver sometimes attended with much difficulty. Under such circum- 
stances a compromise may be made by adjusting the outer blade at the posterior 
extremity of an oblique diameter of the pelvis, and over a lateral angle of the jaw. 

As already hinted at under " Perforation," the great principle in cranioclasis 
or craniotraction is so to apply the instrument and so to make traction that the 
normal mechanism of labor shall be imitated as closely as possible. In other 
words ; traction should be made so that the portion of the presenting part which is 
naturally lowest under normal conditions shall be kept lowest in the pelvis and 
delivered first, as in spontaneous delivery. This principle is often, if not always, 
lost sight of; and because, as is well known, a firmer hold with the instrument can 
be secured over the facial bones, or over the side of the skull over an ear, some 
operators persist in using only these two localities, with an entire disregard of 
the mechanism of labor, thus giving rise to serious, and, as I have seen, fatal com- 
plications. 



CEPHALOTRIPSY. 



1021 



XVIII. CEPHALOTRIPSY. 

Definition. — Cephalotripsy is the crushing of the presenting part by an in- 
strument resembling the obstetric forceps. In 1829 B arid el oc que* invented an 
instrument patterned somewhat after the obstetric forceps, which he designed for 




Fig. i 159. — Cephalotribe Applied at the Sides of the Head. Side View. 



\J 



crushing the fetal head by grasping it in the same manner that the obstetric for- 
ceps, and without previous perforation to force the brain from the mouth, 
orbits, and nose, crushing the cranial bones within an intact scalp, and thus 
preventing edges of fractured bones from doing injury to the maternal soft 
parts. In the early years of its use the cephalotribe 
was intended to abolish the perforator, the craniotomy 
(bone) forceps, and the crotchet. The cephalotribe 
was originally intended only to crush the skull, just as 
the cranioclast is to-day really an instrument designed 
for traction. To-day the cephalotribe is used both as a 
crusher and a tractor. 

Indications. — All forms of cephalotribe, but espe- 
cially the broad-bladed type, are useful to compress the 
head after perforation before it becomes fixed at the 
brim. As a tractor after perforation in the lesser degrees 
of obstructed labor it is also most valuable. A limit for 
the safe employment of the cephalotribe exists, however 
— namely, in pelvic contraction when the clinical index 
of the pelvis is represented by a conjugata vera of three 
inches the safe limit is reached. Much depends, more- 
over, upon the size of the fetal head and the resiliency of 
the cranial bones. To-day the use of the cephalotribe is 
mainly limited to a crushing of the head or breech before 
the application of the cranioclast for purposes of trac- 
tion, and to crushing and extracting the base of the 
skull in the exceptional cases in which the cranioclast 
has slipped and torn away the vault of the skull. In 
such cases the cephalotribe is most useful to secure a 

firm hold on the base of the skull, to crush it, and as a tractor to ex- 
tract the fetus. Practically this is the only way the cephalotribe is to-day 
used by most operators. Some operators still follow perforation with the 




Fig. i 160. — Cephalo- 
tribe Applied at the 
Sides of the Head 
Anterior View. 



*A. Baudelocque: " Revue Med.," August, 1829, p. 321. 



1022 



OBSTETRIC SURGERY. 



application of the cephalotribe as a crusher and an extractor, but for the latter 
purpose the cranioclast is far superior. 

Cranioclast and Cephalotribe Compared. — (i) The cephalotribe is bulkier and 
heavier than the cranioclast and occupies more room in the pelvis than the latter 
instrument, a great disadvantage in contracted pelves. (2) Both, blades of the 
cephalotribe lie outside the fetal skull, and unless the narrow-bladed instrument 
is used — and this is very liable to slip — they do not sink into the scalp as does the 

outer blade of the cranioclast. On the other hand, 
one blade of the cranioclast is hidden in the cranial 
cavity not otherwise occupied, and the outer 
fenestrated blade soon sinks into the scalp and 
thus avoids injury to the maternal soft parts. 
Further, after a short period of traction with the 
cranioclast, the instrument, if properly applied, 
comes to occupy the middle of the pelvis, where 
it can be kept with the left hand from contact 
with the maternal parts. (3) Traction with the 
cranioclast as the head is being drawn through the 
pelvis exerts an even pressure on all points of the 
circumference of the parturient tract, finally elon- 
gating the fetal head, thus diminishing all the pre- 
senting diameters, and even rendering the extrac- 
tion easier as traction is continued. Extensive 
lacerations and injuries to the maternal soft parts 
are of rare occurrence after cranioclasis and 
craniotraction. On the other hand, compression 
of the head with the cephalotribe diminishes only 
one diameter, the compressed one, and corre- 
spondingly increases the opposite ones — namely, 
those non-compressed (Figs. 11 59 and 1160). As 
the head is being drawn through the pelvis, pres- 
sure is thus concentrated at two points of the 
parturient tract instead of being diffused over the 
entire circumference; thus preventing elongation 
of the head as in craniotraction, and rendering the 
extraction more difficult and liable to injure the 
maternal parts. (4) As a rule, the cranioclast 
takes a firmer hold of the fetal head than does the 
cephalotribe, but I have seen many exceptions. 

Instruments. — Practically there are two types 
of the cephalotribe in use to-day — namely, the 
narrow or solid-bladed, and the broad or fenes- 
trated-bladed instruments. Among the narrow or 
solid-bladed instruments are Blot's and Scanzoni's. 
Among the' broad or fenestrated-bladed cephalotribes are Breisky's (Fig. 1161) 
and its] many modifications. Olshausen's cephalotribe (Fig. 1162) is an ex- 
cellent example of the narrow solid-bladed instrument, and Breisky's of the broad 
fenestrated. All of the former are provided with a generous pelvic curve, but the 
cephalic curve is absent in some, as the blades are in close apposition. In the 
latter type of instrument, provision is made for both a pelvic and a cephalic curve : 
the pelvic being 3^ inches (8.2 cm.) in extent, and the cephalic 2j inches (5.7 
cm.), measured from the outer surfaces of the blades. A serious objection 




Fig. i 161. — Breisky's Broad- 
bladed Cephalotribe. 



CEPHALOTRIPSY. 



1023 



exists to each type of cephalotribe, neither of which obtains in the case of 
the cranioclast — namely, the narrow-bladed cephalotribes, whether they possess 
cephalic carves or not, are liable to slip, and the broad type occupies too much 
room in the pelvis, especially when the latter is contracted. 

Operations. — The principles governing the application of the cephalotribe are 
precisely the same as in the case of forceps. Following perforation, projecting 
spiculae of bones must be carefully extracted with the fingers or dressing forceps 
and the exact presentation and position again determined. 

High Cephalotribe Operation (Fig. 1163). — When the head or breech is 
still free above the pelvic inlet, great care must be taken to have the presenting 
part firmly held by an assistant at the inlet by suprapubic pressure. Adap- 
tation of the cephalotribe to the sides of the fetal head at the pelvic inlet is not 
safe, or in fact necessary. Objection has been raised to the use of the cephalo- 
tribe here, that seizing the head antero-posteriorly increases the transverse 
diameters to an equal extent, and that this would be particularly disadvanta- 
geous, especially in contracted pelves (Figs. 1159 and 11 60). This would be 
true were the head fixed transversely in the pelvis, but when the head is 
free it will be found in an oblique diameter, and the cephalotribe seizes 




Fig. i 162. — Olshausen's Narrow-bladed Cephalotribe. 



the head in the opposite oblique and not in an antero-posterior diameter. 
Compensation of head compression thus takes place in an oblique diameter op- 
posite to the one grasped by the instrument and not in a transverse diameter of 
the head. Should, by chance, the head be seized in a transverse diameter, rotation 
of the head with the cephalotribe into an oblique diameter can readily be accom- 
plished. Dragging of a head or breech through the pelvic inlet with so heavy and 
powerful an instrument as the cephalotribe should rarely be attempted, because 
of the danger of pressure of the blades upon the maternal soft parts between the 
symphysis and sacral promontory. Should antero-posterior adaptation occur, 
either spontaneously or artificially, the instrument must be removed and reap- 
plied in a transverse or an oblique diameter, or, better, the cranioclast substi- 
tuted. Compression with the hand-screw should always be slow, and repeated 
digital explorations should be made to detect projecting spiculae of bone. 

Low Cephalotribe Operation. — The left or lower blade is first in- 
troduced at the extremity of the transverse or oblique pelvic diameter according 
to. the position of the presenting part, followed by the application of the right or 
upper blade; great care being used not to injure the uterine or vaginal tissues. 
As in high operations, compression is made slowly with the hand-screw, on the 



1024 



OBSTETRIC SURGERY. 



lookout digitally for bone spiculae, and during extraction the instrument is 
guided and the maternal parts are protected by the fingers of the left hand 
(Figs. 1 163 and 1165). 

Cephalotribe to the Breech. — The same general principles apply here as in 
head presentations, namely, to keep the instrument in an oblique or transverse 
diameter of the pelvis (Fig. 1164). 

After-coming Head. — Although some authorities (Lusk) do not consider 

perforation necessary 




&ss 




-■ Vj^r 



Fig. 1163. — Broad-bladed Cephalotribe Applied in Ver- 
tex Presentation. Median Operation. 



as a preliminary, still 
perforation through the 
floor and roof of the 
mouth before the appli- 
cation of the instrument 
will be found to prevent 
man}" maternal injuries. 
Decapitated Head. 
— In instances of de- 
tachment of the fetal 
head from the body and 
the retention of the 
former in the uterine 
cavity the cephalotribe 
will often prove of use 
in its extraction. The 
head must be steadied 
at the inlet with su- 
prapubic pressure by 
an assistant, and I pre- 
fer to grasp the scalp 
or face from below with 
a strong volsella for- 
ceps as well, and then 
apply the cephalotribe 
to crush and extract. 

Substitutes for Crani- 
oclasis and Cephalo- 
tripsy. — -Although great 
ingenuity has been ex- 
erted to invent other 
and more satisfactory 
substitutes for the op- 
erations of cranioclasis 
and cephalotripsy, still 
in spite of the shortcom- 
ings and defectiveness 
of these latter measures for diminishing the size of the fetal head and breech, 
most obstetric surgeons are agreed that these operations are at the present 
time the best we have at our command. Craniotomy: This was the original 
and now practically obsolete method of diminishing the size of the fetal skull, 
and brought into use various forms of craniotomy forceps. After perforation and 
removal of the brain, one of these bone forceps was introduced under the scalp 
and the parietal, occipital, and frontal bones were seized and broken away piece- 




Fig. 



1 164. — Broad-bladed Cephalotribe Applied to the 
Breech. 




Fig. 



Vertex. Low Operation. 



DECAPITATION. 1025 

meal by a twisting movement of the wrist. The operation was tedious and dan- 
gerous, for unless the maternal soft parts were carefully guarded the withdrawal, 
of the sharp fractured bones caused dangerous lacerations. The craniotomy for- 
ceps of Meigs and Taylor, which were nothing more than heavy bone forceps, 
were at one time generally used in this country. Inquiry of the largest instru- 
ment-makers in New York city shows that the demand for craniotomy forceps 
has practically ceased. Cephalotomy: It has been proposed either to remove 
the fetal head in segments or to divide the skull into two halves. The forceps saw 
of Van Huevel was intended to divide the head from vertex to base into two- 
halves * to remove from the head a triangular segment the apex of which should 
include the bones at the base of the skull. The wire ecraseur has been applied to 
successive portions of the head for the purpose of crushing, as suggested by 
Barnes, of London. f Hubert invented a transforateur which was intended to 
bore through and break up the sphenoid bone, and thus diminish the resistance of 
the base of the skull. Instruments which combined the principles of the trans- 
forateur and the cephalotribe were invented by Valette, Huter, and Solline, and 
were termed sphenotribes. To-day I know of no operation of cephalotomy that 
for effectiveness and safety can successfully compete with cranioclasis. The 
mechanical principles involved in many of the proposed cephalotomy procedures 
are in the main correct, but the instruments are complicated, and some of them 
are too bulky to be used with advantage in cases of pelvic contraction. 



XIX. DECAPITATION. 

Definition. — A separation within the uterus of the fetal head from its trunk. 

Indications. — Infrequently in neglected impacted shoulder presentations 
division of the fetal head from the body is demanded in order to break up the 
triangular wedge which blocks the pelvis; dividing, so to speak, the wedge in two 
parts, thus permitting the deliver}^ first of the fetal body and subsequently of 
the head. The indications are thus almost exclusively in neglected impacted 
shoulder presentation, in which attempts at any form of version to correct the 
malpresentation would jeopardize the already dangerously thinned lower uterine 
segment. The pelvis must have a true conjugate of at least 2 j inches (nearly 
7 cm.), and full dilatation of the cervix must be present or secured artificially. 

Operation. — Various forms of decapitators are in use, ranging from a simple 
whip-cord decapitator to most complicated and expensive embryotomes made up 
of many parts. All types of decapitators may be included among the following : ( i ) 
Karl Braun's blunt hook; (2) Schultze's sickle hook; (3) scissors; (4) the wire ecra- 
seur; (5) various embryotomes, notably those of Pierre Thomas and M. Tarnier; 
(6) the chain-saw; (7) the whip-cord. In default of special instruments, a wire or 
a strong cord may be passed around the fetal neck by means of an English cath- 
eter or perforated blunt hook, and by a sawing motion the neck may be divided 
The chain-saw of the surgeons may be adapted to the same purpose. Much 
difficulty is often encountered in passing the cord, chain-saw, or wire of an ecra- 
seur over the neck, and ingenious and complicated instruments have been in- 
vented to overcome the difficulty. The simplest method is to thread a piece of 
bobbin two feet long into the end of a No. 16 English catheter with stylet in 
place (Fig. 1 180). A curve is next imparted to the catheter by placing it in warm 

* " Diet, de Medecine et de Chirugie," Art. " Embryotomie," page 680. 
f " Obstetric Operations," page 411. 
65 



1026 



OBSTETRIC SURGERY 







water if necessary, and it is then passed around the fetal neck. An end of the 
bobbin is caught with two fingers in the vagina or with dressing forceps, and the 

catheter is finally withdrawn 
with the other end. The bobbin 
encircling the neck is used to 
drag up and around a whip-cord 
or the wire or chain of an ecra- 
seur. In the use of cord, wire, 
or chain great care must be 
used to protect the maternal 
soft parts, and to make sure that 
a portion of the cervix is not 
included in the instrument used. 
The choice of instruments to- 
day usually lies between (i) 
Braun's blunt hook decollator 
(Fig. 1 1 66); (2) a stout pair of 
scissors, as Dubois's (Fig. 1168); 
(3) a curved knife-edge hook, 
as Schultze's or Ramsbotham's 
(Fig. 1 167). Perhaps nowhere 
more than in obstetrics does 
tradition influence one in the 
choice of instruments and opera- 
tive procedure. For this reason 
the blunt decapitating hook of 
Braun is described and recom- 
mended by each obstetric writer 
in turn. After many unpreju- 
diced comparisons of the Braun 
hook with a strong pair of scis- 
sors and the knife-edge hook, I 
am unable to understand why 
one should prefer such an awk- 
ward and unscientific instru- 
ment as the first to either of 
the latter. My choice of in- 
struments is for the scissors 
and sickle knife. I rarely if ever use a Braun's hook, except occasionally for 
demonstration. The space occupied by each of the three instruments in a 
narrow pelvis is about the same, the choice, if any, being in favor of the scissors. 





Fig. i i 66. — Braun ' s 
Decapitating Hook. 



Fig. 1167. — Decapi- 
tating Sickle 
Knife of Schultze. 




Fig. 1168. — Dubois's Decapitating 



xeral Embryotomy Scissors. 



DECAPITATION. 



1027 



i. Braun's Blunt Hook Decollator (Figs, n 66 and 1169). — This instru- 
ment is a modified blunt hook with its end bent nearly at an acute 
angle, flattened somewhat from side to side, and terminating in a blunt 
button shaped like the end of a foil. The handle, formerly of ebony but 
now cast in one piece with the rest of the instrument, is set at right 
angles, thus imparting when grasped with the whole hand a powerful lever- 
age movement to the hooked end. Operation: Every instrument should 
be thoroughly tested upon a piece of soft wood, such as pine kindling, before 
being put into use, to avoid an unexpected break and to guard against injury 
to the soft parts of the mother. 
Decapitation is usually performed 
in shoulder presentation, and 
although, so far as I am aware, 
no text-book mentions the fact, 
still I have found in practice that 
there is a distinct choice of hands 
to be used in left and right shoulder 
positions. In all cases if an arm 
is prolapsed, it is advisable to apply 
a sling to it and have an assistant 
make firm traction on it to fix 
the shoulder firmly in the pelvic 
inlet. In left shoulder positions it 
is advisable, if the operator has 
sufficient control over his left 
hand, to encircle the fetal neck 
with the fingers of the right hand, 
the thumb to the front of the neck, 
namely, in the anterior portion of 
the pelvic inlet , in both anterior and 
posterior right shoulder positions, 
and index and other fingers behind. 
The neck is then grasped firmly and 
with the aid of the prolapsed arm 
drawn down as far as possible into 
the pelvis. The hook of the decol- 
lator is next carefully passed with 
the left hand behind the symphy- 
sis, along the right thumb of the 
operator as a guide, and the but- 
ton end of the hook passed over 
the neck and received by the right 
index finger at the other side of 
the neck and in the rear of the 

pelvis. The handle of the instrument is now seized with the left hand and by a 
rotary motion of the instrument between the index finger behind and the thumb 
in front, thus guarding the point at all times as far as possible, the neck tissues, 
portion by portion, are seized by the button point and twisted off until the spinal 
column is divided with the same rotary motion or by direct downward traction 
on the remaining soft tissues of the neck. Separation of these last tissues by 
twisting and downward traction must not be too sudden, lest the sudden freeing 
of the hook penetrate the maternal soft parts. This accident may be avoided 




Fig. 



1 169. — Method of Decapitating 
Braun's Decapitating Hook. 



1028 



OBSTETRIC SURGERY. 



by care in the use of the hook or by substituting a pair of scissors or a sickle 
knife to divide the last few shreds of tissue. In right shoulder positions I have 
found it most convenient to reverse the position of the two hands of the oper- 
ator, using the left hand to encircle the neck and the right to rotate the instru- 
ment. This is the usual position of the shoulder illustrated in the text-books, 
whereas the left scapulo-anterior is the most common, and the use of the oper- 
ator's hands in this position is thus left to the imagination. 

2. Sickle-Knife or Curved-Saw Decapitators. — A more convenient and 

safer mode of decapitation, even 
for the experienced operator, is 
a sickle knife (Figs. 1167, 1170, 
and 1 171), or a decapitating 
hook with serrated edge. I am 
accustomed to use the scissors 
in conjunction with one of these 
instruments to the exclusion of 
the unscientific and awkward 
Braun's hook. Operation: Each 
instrument should be carefully 
tested before use. The shoulder 
should be brought as low in the 
pelvic inlet as possible by trac- 
tion with a sling upon a pro- 
lapsed arm. In left shoulder 
positions we encircle the neck 
with the right hand and with 
the left carry the decapitator up 
in front of the neck, the point 
being directly toward the head 
when the level of the neck is 
reached, pass the point over the 
neck and palpate behind with 
the internal or right fingers to 
make sure that the instrument is 
properly adjusted over the fetal 
neck. The point being guarded 
with the internal hand, the de- 
capitator is now drawn firmly 
downward and with a to-and-fro 
movement, as far as the vaginal 
outlet will permit, the neck is 
quickly cut through (Fig. 1171). 
A common mistake with the 
novice is, after the vertebras 
are divided, to incline the plane of section into the fetal body or shoulder 
instead of cutting through the remainder of the neck. Repeated palpation 
with the internal hand will prevent this error, which unnecessarily prolongs 
the operation. The last shreds of cervical tissue should not be too suddenly 
divided lest the sudden release of the decapitator lacerate the maternal soft 
parts. In right scapulo-positions the left fingers encircle the neck and the 
decapitator is used in the right hand outside of the vulva. In both right and 
left positions the point of the sickle knife or curved saw decapitator should be 




Fig. 1 i 70. — Method of Decapitating with De- 
capitating Sickle Knife of Schultze. 



DECAPITATION. 



1029 



pointed to the posterior part of the pelvis to avoid injury to the bladder, and 
the handle during the pendulatory movement inclined as far forward as possible. 
We thus, by cutting downward and forward, avoid injuring the rectum. 

3. Decapitation with Blunt Scissors (Figs. 1168, 1172). — Although the 
objection has been raised to the scissors decapitator that it is apt to wound the 
maternal soft parts or the operator's fingers, yet this method after a little practice 
on the manikin will usually prove a safe and rapid one and will be selected in pref- 
erence to the Braun hook or curved knife or saw methods. Operation: The arm 
is prolapsed as in the first two methods, and the choice of hands is the same. The 
cutting should be done from below upward, the outer surface of the blunt points 
being guided with the internal finger. Some difficulty may be experienced in 
dividing the last few shreds of tissue at the upper part of the neck, and this can be 
overcome by hooking the index-finger over the string of tissue, drawing it down 




H U ' 




Fig 



1 17 1. — Method of Holding the 
Sickle Knife Decapitator. 



Fig. 1 172. — Decapitating with Scissors. 



into the vagina, and cutting along the finger as a director. All the decapitating 
scissors have a common fault, namely, the handles are too small, admitting only 
one finger into each. In active use these fingers become bruised and numb by 
reason of the severe pressure to which they are subjected. To overcome this 
objection I have had made both a straight and a curved pair of obstetric scis- 
sors with handles to admit several fingers. These scissors are powerful and 
convenient, and serve equally well for decapitation, eventration, amputations of 
extremities, or spondylotomy. 

Extraction after Decapitation. — Toward the end of the operation the fetal 
head should be fixed at the pelvic inlet by suprapubic pressure by an assistant 
(Fig. 1 1 77). The obstructing wedge should be broken up by the complete sever- 
ing of the neck, when the fetal body may be readily delivered by traction upon 
the prolapsed arm. The head may possibly be delivered spontaneously; it is 




1030 OBSTETRIC SURGERY. 

best, however, not to wait for uncertainty, but to pass the hand up and manually 
deliver at once, (i) The stump of the vertebral column should be palpated 
for sharp projecting vertebras, and if, as usually happens, none are present, 
two fingers are passed into the mouth and the thumb over the base of the 
skull for counter-pressure and the head is delivered manually in a face pres- 
entation (Fig. 1 173). 
- ■...__.._ __ ■*""' (2) If much resist- 

ance is met with, 
the blunt hook or a 
crotchet, if one is at 
*\x hand, may be sub- 

stituted for the fin- 
gers in the mouth. 
(3) If a sharp project- 
ing vertebral stump 
HWHV. exists, extraction in 

face presentation may 

J : ^T dangerously lacerate 

^ the maternal soft 

Fig. i 173. — Manual Extraction of the Decapitated Head, parts. It IS then 

better either to ex- 
tract the head vertex first with the forceps, or to perforate the vertex and 
extract with a cranioclast (Fig. 1158), or with two fingers wrapped with 
aseptic gauze and passed into the opening in the skull, and the thumb over 
the occipital bone for counter-pressure. The gauze is to protect the fingers from 
laceration by the cranial bones. (4) In contracted pelves, perforation and ex- 
traction with the cranioclast or cephalotribe should be the method of election 
(Fig. 1 158). 



XX. EXENTERATION OR EVISCERATION. 

By this is meant the opening of the thorax or abdomen, or of both, and the 
removal of their contents. 

Indications. — The most common indication is in case of shoulder presentation 
in which decapitation fails or is impossible, especially when the head and neck are 
so high above the pelvic inlet as to be difficult to reach. Evisceration is occasion- 
ally demanded in cases of monsters after perforation, extraction of the head, 
and cleidotomy, and of fetal tumors, as cystic kidney, ascites, or distended 
bladder. 

Operations. — The opening into the abdomen or thorax can be made with any 
of the perforators, or with a straight or curved pair of Dubois scissors, whichever 
is most convenient. No matter what instrument is used, the maternal parts 
must be carefully guarded from injury; and if the part to be perforated is at all 
movable, it should be firmly grasped with stout volsella forceps and fixed at the 
inlet by suprapubic pressure. When the chest is entered, it is advisable to secure 
an ample and permanent opening either by enlarging the original opening made 
with the perforator by turning the instrument so asto'make a second incision at 
right angles to the first, or, better still, by cutting away several segments of ribs 
with the heavy Dubois scissors. The viscera are removed with strong volsella 
forceps, first breaking them up, if necessary, with the perforator or scissors. In 
shoulder presentation the abdominal cavity may be reached directly from the 



AMPUTATION OF EXTREMITIES— CLEIDOTOMY. 1031 

thorax by perforating the diaphragm, and, again, in difficult breech extractions 
the thorax can be opened from the abdomen by the same route. After eviscera- 
tion in impacted shoulder presentation the simplest method of delivery should be 
chosen, (i) Usually the reduced bulk of the fetus renders it easy and safe to 
pass up the appropriate hand, seize the feet or head, and do an ordinary podalic 
version without injury to the distended uterine segment or cervix, thus imitating 
nature's method of spontaneous version. (2) Should difficulty be experienced, a 
further operation of disjointing the spine with the Dubois scissors in the dorsal 
region may be performed, and, the fetus being divided in halves, each half is 
separately delivered. (3) In cases of macerated or small fetuses it will not be 
necessary to divide the spine, but with a blunt hook the fetus may be doubled 
upon itself and delivered in imitation of nature's method in spontaneous evolu- 
tion. This method of delivery is facilitated by prolapse of an arm, for then 
traction can be made upon both blunt hook and prolapsed arm at one and the 
same time. Extraction after mutilation of the fetal soft parts requires no 
special technique, as the reduction in size is supposed to be so thorough that 
general principles will suffice. 



XXI. AMPUTATION OF EXTREMITIES. 

Only rarely is the obstetrician called upon to amputate an extremity or 
several extremities. Possibly it may be demanded in cases of fetal monstrosities 
and impaction of multiple presentations (page 613). The amputation is best 
performed with the curved obstetric scissors. 



XXII. CLEIDOTOMY. 

Cleidotomy or division of both clavicles is an obstetric operation which has for 
its object the diminution of the bisacromial diameter of the dead fetus, when the 
shoulders obstruct its passage. This simple operation, rarely mentioned in the 
text-books, has never, I believe, taken its proper place in obstetric surgery, as a 
means of lessening maternal morbidity and mortality. How often we hear of in- 
stances in which, after perforation and extraction of the fetal head in the case of a 
generally contracted pelvis or outlet, or an excessively large child, twenty minutes 
or more were spent in extraction of first one and then the other shoulder, thereby 
adding perhaps to the already existing shock! As a matter of routine in these 
cases I am accustomed to divide the clavicles, and it is amazing how the diminu- 
tion of the bisacromial diameter thus produced renders the subsequent extrac- 
tion of the fetal shoulders a comparatively easy task. In a number of instances 
at the Emergency Hospital, in which birth of the head had been accomplished by 
forceps or perforation and craniotraction, the shoulders resisting all ordinary 
methods of extraction, the simple operation of cleidotomy completely changed the 
clinical picture. From measurements taken at the bedside, and from experi- 
ments upon fetal cadavers, I have found that the bisacromial diameter is in 
cleidotomy readily reduced from 5 inches (12.7 cm.) to 3J inches (8.89 cm.). 
Figs. 1 175 and 11 76 show a fetal cadaver, photographed on the same scale 
before and after cleidotomy. 



1032 



OBSTETRIC SURGERY. 



Operation. — This is best performed with the curved obstetric scissors (Fig. 
n68),two fingers of the left hand being used to guide the blunt points to the 




Fig. i 174. — The Operation of Cleidotomy, Performed with Long Curved Scissors. 






Im KKm K SB^ M 



.4-2 in 




Fig. 1175. — -Fetal Cadaver before Clei- 
dotomy. 



Fig. 1 1 76. — Fetal Cadaver after Clei- 
dotomy. 



middle of each clavicle. It will usually be necessarv to extend or flex laterally 
the fetal head strongly so as to give room for the use of -the scissors. (Fig. 1 1 74) . 



EXPRESSION OF THE FETUS. 



1033 



XXIII. SPONDYLOTOMY. 

Spondylotomy is an operation for dividing the spinal column of the fetus very 
much as it is divided in decapitation, and has been recommended * as an alter- 
native for the latter operation. The operation as well as the subsequent extrac- 
tion requires more time and is more difficult than decapitation. 



(C) OPERATIONS FOR DELIVERY. 

I. EXPRESSION OF THE FETUS. EXPRESSIO FOETUS. 

(Fig. 1 177.) 

Definition. — Expression of the fetus is the term applied to the method of de- 
livery of the child by the exertion of pressure upon the fundus of the uterus. It 




V 



\ 



f 



< 



Fig. 1 177. — Expression of the Fetus. Expressio Fcetus. — {From a photograph taken 

at the Emergency Hospital.) 



acts by increasing the intra-abdominal pressure and stimulating the uterine 
muscle to contraction. In one form or another this principle has been employed 
from the earliest times by people of all nations, civilized and barbarous. 
♦Professor A R. Simpson, of Edinburgh. 



1034 OBSTETRIC SURGERY. 

Indications. — Some hold that this method may complete delivery in the en- 
tire absence of pains, but it is usually adopted only as a means of increasing the 
duration and strength of the normal uterine contractions. In this way it is used 
at the end of the second stage when the uterine contractions lack force and the 
external genitals are not too tense and narrow. With a small fetus it may be of 
great value when there is an indication for immediate delivery. In such a case 
expression may complete the expulsion of the fetus more rapidly than any other 
procedure. When pains have been weakened by anesthesia and the fetus is in 
danger it is of value. A further indication results from failure of the head to en- 
gage in the brim of the pelvis, although the uterus is contracting strongly and no 
disproportion between the size of the head and that of the inlet exists. Such 
a condition is present when a pendulous abdomen permits a marked anteversion 
or anteflexion of the uterus. The same result may occur from the presence of a 
maternal umbilical or ventral hernia. Under these circumstances properly ap- 
plied pressure upon the abdominal wall will cause the head to enter the brim and, 
assisted by the natural expulsive force of the uterus, it will advance rapidly. In 
delivery of the second twin, expression is sometimes of assistance, but great care 
must be exercised that the uterus is not emptied too suddenly. 

Contraindications. — The presence of a large amount of fat in the abdominal 
wall interferes seriously with the manceuver. Marked tenderness and tonic con- 
traction of the uterus are absolute contraindications. If inflammatory con- 
ditions of the adnexa are present, external pressure may lead to dangerous re- 
sults. Disproportion between the size of the fetus and of the parturient canal, 
whether from narrowing of the pelvis or rigidity of the soft parts or other cause, 
should prevent its employment. 

Operation. — The woman is placed in the dorsal position, close to the edge of 
the bed or upon a table. Anesthesia is of value in some cases, but in others it is 
not desirable, as it diminishes the natural uterine contractions. The operator, 
standing at the right side, grasps the fundus between the two hands and exerts 
pressure upon the uterus in the axis of the inlet (Fig. 117 7). This is done only 
during the uterine contractions, beginning gently and gradually increasing the 
amount of force employed. During the interval between the pains the uterus 
may be gently massaged. Care must, of course, be exercised, as in the Crede 
method of placental expulsion, that no injury is done to the appendages by the 
use of undue force improperly applied. Even when the method is adopted in 
cases in which there are no natural uterine contractions, intermittent pressure 
alone should be used, imitating, as far as possible, the normal labor pains. 



II. FORCIBLE DELIVERY. ACCOUCHEMENT FORCE. 

Definition. — By accouchement force we understand three operations: viz., (1) 
the complete rapid instrumental or manual dilatation of the cervical canal; fol- 
lowed (2) by either combined or internal version or the application of the for- 
ceps; and (3) the immediate extraction of the child. The accouchement force 
of the old writers upon obstetrics was often quite another and more serious 
operation, for the condition of the cervical canal was frequently lost sight of 
and the operation too frequently meant, (1) the plunging of the hand or the 
application of ^ the forceps through a cervical canal imperfectly dilated or torn 
by the insertion of the hand, and (2) the immediate extraction of the fetus 
through this constricted or lacerated os. That the latter definition of the term 



FORCIBLE DELIVERY. 1035 

still obtains is proved by the accidents that are constantly occurring during the 
extraction of the fetus. 

Indications. — In the event of placenta praevia when the hemorrhage has been 
temporarily arrested and there is necessity for immediate evacuation of the 
uterine contents, there is probably presented the most urgent indication for the 
performance of this operation. In case of the sudden death of the mother this 
procedure is indicated only when there is hope of delivering the child more 
quickly by this method (see Post-mortem Delivery, page 728). In cases of 
eclampsia when other means fail and it is necessary to empty the uterus, this 




Fig. i 178. — Dangers of a Rapid Breech Extraction through an Imperfectly Dilated 
Os. The external os is not fully dilated or is paralyzed. Traction on the legs results 
in extension of the head and arms. 

method may be indicated, as rapidity is required, since convulsions are more 
likely to occur as long as manipulation of the uterus continues. 

Dangers. — Unless performed in the most rapid and scientific manner, this 
operation is full of danger, being attended by a high percentage of maternal 
mortality. It is apt to be very destructive to the tissues of the uterus. In 
placenta praevia the danger of uterine rupture and infection is a contraindica- 
tion to this procedure. 

Operation. — (See Manual Dilatation of Cervix, page 963, and Version, page 
987, also Breech Extraction, page 1038.) 



10 36 OBSTETRIC SURGERY. 



III. MANUAL EXTRACTION OF THE FORE-COMING HEAD. 
RITGEN'S METHOD (Fig. 1179). 

Definition.— The digital extraction of the head in head-first deliver}- at the 

end of the second stage by the introduction of two fingers into the rectum of 

the mother, favoring extension of the head, in vertex presentation, through the 

vulval orifice. The operation is often combined with that of expressio foetus. 

Indication. — Tedious or powerless labor at the end of the second stage; when 

the relative indication for the 
forceps exists at this time and 
no instrument is available. 
It may also be employed 
when the pains are so severe 
that control of the head is 
impossible. In this case an 
anesthetic is given and the 
head is extracted in the inter- 
val between contractions. 

Dangers. — Injury of the 
rectal mucous membrane of 
the mother or of the eyes of 
the fetus is liable to result 
from too vigorous or care- 
lessly applied pressure. I 
have seen severe venous 
hemorrhage. The operation 
is not aseptic. 

Operation. — Anesthesia is 

not necessary, but in great 

rigiditv of the part its use is 

Fig. i 179.— Manual Extraction of the Fore-com- desirable, especially in primi- 

ing Head by the Introduction of Two Fingers m /- r .i/u 

into the Rectum. Ritgen's Method. P^rae. I wo fingers ot the 

right hand are introduced 
into the rectum and continued pressure is brought to bear in vertex presenta- 
tion upon the forehead, the malar prominences, the superior maxilla, or the 
chin, thus gradually extending the head through the ostium vaginae. Great care 
must be taken to avoid pressure upon the eyes. Similar procedures are advo- 
cated by others, viz., combining pressure upon the face of the fetus by one or two 
fingers in the rectum with restraint of the head during its advance by pressure 
applied to the exposed portion of the vertex. The aim of all is to advance the 
head gradually, in the absence of uterine contractions or in the intervals between 
pains, under anesthesia in cases in which the contractions are so severe and fre- 
quent that protection of the perineum is impossible without an anesthetic. It is 
preferable to avoid the lack of asepsis involved in this operation by using a suffi- 
cient amount of pressure upon the fundus to enable the middle finger of the right 
hand to obtain a point of pressure upon the forehead of the fetus by reaching 
behind the anus, without entering the rectum. (Compare Perineal Protection, 
page 532 and Fig. 624). 




SHOULDER EXTRACTION IN HEAD-FIRST CASES. 



1037 



IV. SHOULDER EXTRACTION IN HEAD-FIRST CASES. 

After the birth of the head there sometimes occurs delay in delivery 
of the shoulders, which may result in the death of the fetus from pro- 



CERVIC^ACRbMIALD. 





Fig. i 180.— Shoulder Extraction in 
Head-first Labors. Directing the an- 
terior shoulder well up behind the sym- 
physis, thus securing the engagement of 
the cervico-acromial diameter. 



Fig. iiSi. — Shoulder Extraction in: 
Head-first Labors. Delivery of the 
posterior shoulder, either spontaneously 
or artificially. 



longed pressure upon the cord. Such delay may be of maternal origin, 
from inefficient contractions, pendulous abdomen, etc. Fetal causes include- 
actual shortness of the umbilical 
cord or relative shortness from the 
presence of loops around the neck 
or body; failure of rotation; diseases, 
such as ascites; deformities of the 
fetus, and relative or actual large- 
ness of the fetal shoulders or chest, 
(i) If the pains are weak, and after 
allowing the uterus a little rest, 
stimulation of the fundus is indi- 
cated. (2) If a pendulous abdomen 
retards expulsion, supporting the ab- 
domen and uterus and exerting pres- 
sure upon the fundus may obviate the 
difficulty. (3) If expulsion of the 
shoulders is retarded by actual short- 
ness of the cord, it may be necessary 
to ligate it in two places and cut 
between the ligatures. If the cord is around the neck, the loop should be 




Fig. i 182. — Shoulder Extraction in Head- 
first Labors. Delivery of the anterior 
shoulder by depressing the head and mak- 
ing gentle downward traction upon it. 



1038 



OBSTETRIC SURGERY. 



drawn down if possible and passed over the head so as to relieve it; failing 
in this, it should be loosened by traction and the body delivered through the 
loop (Fig. 616). If this is not accomplished, it must be divided between 
ligatures. (4) If the delay is from failure of rotation, one may aid restitu- 
tion of the head and thus cause rotation of the shoulders into the conjugate 
diameter. But if this fails, rotation of the shoulders may be obtained by direct 
pressure of the fingers in the vagina. If one is again unsuccessful, or if uterine 
stimulation and pressure do not overcome the obstruction due to a large chest, 
ascites, or a monstrosity, extraction of the shoulders is indicated. Mutilatory 

operations are a final resort. 
(5) In extracting the shoulders 
traction is best employed only 
during the pains. I am accus- 
tomed to hold the head in the 
%^| hand and gently raise it so that 

the anterior shoulder is well 
V ^^ up behind the symphysis, thus 

securing at the outlet the cer- 
vico-acromial diameter of the 
fetus instead of the bisacromial 
diameter (Fig. 1180). The pos- 
terior shoulder is now delivered 
over the perineum by pressure 
on the fundus (Fig. 1181), trac- 
tion on the head (Fig. 1181) or 
in the axilla. The posterior 
shoulder is thus delivered first, 
contrary to the custom of many. 
(Compare Shoulder Delivery, 
page 538.) (6) The anterior 
shoulder, up to this time behind 
the symphysis, is now delivered 
by depressing the head, and 
making gentle downward trac- 
tion upon it (Fig. 1182). Traction with a finger in the anterior axilla may 
be necessary. (7) Some advise pushing up the anterior shoulder until the 
neck is under the pubic arch, drawing downward until the posterior shoulder 
is at the edge of the perineum, then carrying the head backward, so that 
the anterior shoulder may emerge under the arch (Fig. 1183). (8) Blunt hooks 
are sometimes advised for exerting traction in place of the finger. Either 
may cause fracture of the humerus, separation of its epiphysis, or temporary 
paralysis of the arm. The blunt hook is the more likely to cause such damage. 




Fig. i 183. — Extraction of the Posterior 
Shoulder by Traction with One Finger in 
the Posterior Axilla and the Palms of the 
Hands upon the Head. 



V. BREECH EXTRACTION. 

The general rule for the conduct of labor with breech presentation is to do only 
what is necessary to prevent early rupture of the membranes and so to obtain as 
complete dilatation of the parturient canal as possible before passage of the head. 
If everything progresses favorably, the physician is called upon to do nothing 
until the umbilicus is delivered, except to support the trunk after it is born, and 



BREECH EXTRACTION. 



1039 



to watch the fundus carefully and constantly in order to prevent displacement of 
the arms above the head. Occasionally, however, the breech may be arrested 
either above or at the brim, or in the pelvic cavity. 

Dangers. — Injury to either the mother or the fetus may result from breech 
extraction. Fracture or dislocation of the femur of the fetus, injury of the femo- 
ral blood-vessels, or temporary paralysis of the lower extremities may follow 
traction by any method involving pressure in the groin, but is most likely to take 
place when the blunt hook is used. Laceration of the maternal soft parts may be 
caused by a slipping of the blunt hook or of the forceps applied to the breech. 
The forceps may also injure the spinal cord or abdominal organs of the fetus, 
and the blunt hook the genitals. It is thus seen that serious results may 
follow the application of the forceps or the careless use of the blunt hook, and 
therefore these procedures should not be indiscriminately employed. 



(A) ARREST OF THE BREECH ABOVE THE PELVIC INLET. 

Obliquity of the uterus may cause the breech to rest upon the pelvic brim, pre- 
venting its advance. When this occurs, the fetus may be raised slightly and the 
breech pushed over the pelvic inlet 
and held in that situation until it has 
engaged. This manceuver may be exe- 
cuted by external abdominal manipu- 
lation or by two fingers in the vagina '' ^^^ 
or by the two combined. 

(B) ARREST OF THE BREECH AT 
THE INLET. 

This may be due to contraction or 
deformity of the pelvis or to unusual 
size'of the fetus. At times the obstacle 
may be overcome by simple pressure 
upon the fundus. If this fails breech ex- 
traction may be demanded for the fol- 
lowing indications : on the part of the 
mother: (i) Exhaustion from pro- 
longed efforts at expulsion, (2) severe 
hemorrhage, (3) rise of temperature, 
(4) convulsions, (5) prolonged compres- 
sion of the soft parts, (6) varicosities 
or oedema of the external genitals. In- 
dications on the part of the fetus are : 

(1) Commencing asphyxia, shown by 

increased rapidity and later slowness and irregularity of the fetal heart; 

(2) prolapse of the cord. Arrest of the breech At the brim of the pelvis may be 
overcome by one of the following procedures, which can be assisted by pressure 
upon the fundus. Whichever method is employed, it is imperative to keep 
the fundus closely in contact with the^fetus, in order, as has been stated above, to 
prevent displacement of the upper extremities above the head. Any form of 
traction used should be exerted only during the pains. 




Fig. 1184. — -Breech Extraction with the 
Breech at or above the Pelvic Inlet. 
Bringing down the Anterior Leg. 



1040 



OBSTETRIC SURGERY. 




Fig. 



5. — Breech Extraction. Delivery 
of a Small or Premature Fetus by 
Direct Manual Traction upon the 
Breech, the Thumb and Third and 
Fourth Fingers in the Groins, and the 
First and Sacond Fingers over the 
Back of the Fetus. 



1. Traction upon a Leg Brought Down (Fig. 1184). — Under anesthesia the 
hand whose palm can most conveniently be placed upon the abdominal surface of 
the fetus is introduced into the uterus in this position. The anterior foot is seized 
and brought down. It is important that this foot should be chosen rather than 

the posterior, because in the latter 
event traction tends to bring the an- 
terior buttock over the front portion 
of the brim of the pelvis, thus pre- 
venting descent. Care must be 
taken that prolapse of the cord does 
not occur when the foot is brought 
down. After the foot has been drawn 
out of the vulva traction on it is 
exerted downward and backward in 
the axis of the pelvic inlet (Fig. 1189). 
Pressure upon the fundus aids in 
bringing the posterior groin within 
reach, when one or two fingers intro- 
duced into it may further assist 
extraction by distributing the force 
over both lower extremities and so 
diminishing the danger of injury to 
the one brought down (Fig. 1190). 
The other foot may be brought down 
also, but better dilatation of the soft parts is obtained when this is not done. 
Traction downward and backward is continued, the extremities being wrapped 
in a hot sterile towel. As the breech emerges it is drawn forward to avoid 
lacerating the perineum. If the legs are extended along the body, and this is 
discovered early by abdominal palpation before rupture of the membranes, the 
difficulty can be overcome by ex- 
ternal podalic version. If not 
seen until later, great care must 
be used in flexing the extended 
leg. I introduce the hand as far 
as the popliteal space, and with 
two fingers encircling the upper 
third of the leg gently flex the 
same downward. The leg and 
the foot are thus easily reached 
and brought down. This pro- 
cedure is better than that of in- 
troducing the hand deep into the 
uterus to reach the feet near the 
fundus. 

2. Digital Traction. — If a foot 
is not or cannot be brought down, 
a finger passed through the an- 
terior groin may serve for applying traction. As soon as this, aided by 
pressure upon the fundus, has brought the posterior groin within reach, 
two fingers of the other hand in this groin can be used to assist. Va- 
rious modifications of digital traction are advised by different operators. 
Some apply pressure in the posterior groin by an index-finger in the mother's 




THE 



Fig. i 186. — Double Sling Applied to 
Breech, showing Faulty and Correct Lines 
of Traction. 



BREECH EXTRACTION. 1041 

rectum while the corresponding finger of the other hand is employed in the ante- 
rior groin. Others exert traction by the whole hand in the vagina with the 
thumb over one iliac crest of the fetus and the little finger over the other, while 
the remaining fingers are extended along the back (Fig. 1185). 

3. The Fillet (Fig. 1186). — This may be used when the groin cannot well be 
reached in order to exert traction, and also when a greater amount of force is re- 
quired than can be commanded by the digital method. The fillet, a strip of 
sterile bandage, is passed up to and across the anterior groin and down on the 
other side of the thigh, forming a loop over the groin. Some obstetricians employ 
a second fillet over the opposite inguinal region in order to be able to use greater 
force without increasing the strain upon one portion of the body. The fillet may 
be carried into position by a loop of string attached to a catheter containing a 
stylet (Fig. 1 1 18). The latter is bent so as to form a curve, which when passed up 
to the groin, turned toward the child's abdomen, and drawn down into the 




x 





■ _ . - 






Fig. i i 87. — Breech Extraction. Slixg Applied to the Anterior and the Blunt 

Hook to the Posterior Groin. 

groin, will bring its tip, threaded with a loop of string, between the thighs of the 
fetus. This loop is seized, drawn down, and fastened to the fillet. When the 
catheter and stylet are withdrawn the fillet passes into position. In exerting 
traction by means of the fillet, care must be taken to pull during the pains in 
such a direction as to correspond with the mechanism of labor and so to diminish 
the liability to fracture the femur. 

4. The Blunt Hook (Fig. 1 187). — A blunt hook, consisting of a straight shank 
with an extremity whose curve should be such as to fit the inguinal region of the 
fetus, is advised by some as affording means for stronger traction. It is passed up, 
as is the catheter for placing the fillet, between two fingers of the left hand and 
the child's body. Its point is rotated so that when drawn down its curve lies in 
the groin and its point is felt between the thighs. The same precautions must 
be taken in regard to the line of traction as with the fillet. With this, as with 
the fillet, a finger in the groin may assist when the breech has been brought 
sufficiently low. 
66 



1042 



OBSTETRIC SURGERY. 



5. Forceps.— This may be applied to the breech as a last resort. (See For- 
ceps, page 1054.) 



(C) ARREST OF THE BREECH IN THE PELVIC CAVITY. 

When impaction of the breech occurs in' the pelvic cavity, it is usually impos- 
sible to bring down a foot. The obstetrician must rely upon external abdominal 
pressure alone, or combined with digital traction in the groin, or the use of the 
filletTor blunt hook. The forceps may be employed as in cases of arrest at the 

brim. Symphyseotomy has 
been advised in these cases. 
When the child is dead and 
other methods have failed, 
the cranioclast applied to the 
breech will usually succeed in 
effecting delivery. One blade 
is introduced into the fetal 
rectum, the other applied over 
the sacrum (Fig. n 57), or the 
cephalotribe may be applied 
over the trochanters and sides 
of the pelvis if it is necessary 
to diminish the breadth of the 
breech (Fig. 11 64). 

The uterus must be made 
to retract closely over the fetus 
during the whole period of its 
delivery. This is best accom- 
plished by having an assistant 
grasp the fundus with both 
hands, making a funnel, thus 
preserving head flexion and re- 
ducing the danger of displace- 
ment of the arms (Fig. 1177). 
Traction should be made dur- 
ing the pains when the latter 
are not too far apart ; it should 
be slow to allow the uterus 
completely to retract and thus 
lessen the danger of hemor- 
rhage; the direction of the 
traction should be downward 
and somewhat backward, and steady tractions are preferable to rotary or pen- 
dulum movements. 

j Extraction by the Feet (Fig. 11 89). — If a single leg presents, the foot is 
seized between the middle and index fingers with the thumb on the sole, and when 
the leg is drawn outside the vagina the leg is wrapped in a warm towel and grasped 
with the whole hand, the thumb always being directed upward and applied to 
the dorsal surface of the leg. The fetus as delivered should always be covered 
with warm moist towels (ioo° F. ) to lessen the danger of the air of the delivery 
room ( 70 to 8o° F. ) exciting respiratory movements. The direction of the 
traction should be sufficiently backward to avoid friction at the pubic arch, and 




Fig. 1 188. — Breech Presentation with the Left 
or Anterior Buttock Caught at the Pelvic 
Inlet behind the Symphysis, as the Result 
of Faulty Traction on the Prolapsed Leg in 
a Horizontal Plane. 



BREECH EXTRACTION. 



1043 





Fig. iil 



•Breech Extraction. Trac- 
tion on a Leg. 



Fig. i 190. — Breech Extraction. Trac- 
tion on the Anterior Leg and Groin 
and Posterior Groin. 





Fig. 1191. — Breech Extraction. Trac- 
tion on Both Groins. 



Fig. 1 192. — Breech Extraction. Down- 
ward Traction on the Groins. 




Fig. 1 103. — Extraction of the After-coming Head. Delivery of the Posterior 



Arm. 



10 44 OBSTETRIC SURGERY. 

until the buttocks appear the extracting hand should shift upward so as to grasp 
the leg as near the maternal parts as possible; whichever leg is seized rotates for- 
ward into the pubic angle during extraction. Should both legs present in the 
vagina, the middle finger is placed between the feet and the index and ring fingers 
encircle the external malleoli until the legs are delivered, when the right leg 
should be seized with the right hand and the left with the left hand. The nor- 
mal rotation of the fetus can thus be controlled. Leg traction should, by reason 
of the dangers of dislocation and fracture, be discontinued as soon as the buttocks 
have been brought into the vulval outlet, when traction on the breech should be 
substituted (Figs. 1190, 1191, 1192). 

Extraction by the Breech (Fig. 1193).— The fetal pelvis is grasped by inserting 
an index-finger in each groin, placing the thumbs over the fetal sacrum, and 
steadying the remaining three fingers of each hand over the corresponding 
thighs. Following the normal mechanism, the fetus is now slowly extracted 
until the lower angle of the anterior scapula appears, during which time atten- 
tion should be paid to the cord. 

Management of the Cord. — Should the cord be found between the child's legs, 
the placental extremity should be drawn down and the loop, if possible, slipped 
over the posterior thigh. In rare cases, when this procedure fails, the cord should 
be cut between two ligatures. In all cases as soon as the umbilicus appears at the 
vulva the cord should gently be drawn down a few inches and placed, if possible, 
in the posterior segment of the outlet, in order to avoid dangerous traction upon 
the navel. 



VI. EXTRACTION OF THE AFTER-COMING HEAD. 

(1) Delivery of Displaced Arm. (2) Manual Rotation of Transversely Placed Head. (3) 
Uterine Compression. (4) F ace-and- shoulder Traction, or Smellie Method. (5) Jaw- 
and-shoulder Traction, or Method of Smellie-Veit, Mauriceau. (6) Jaw Traction and 
Suprapubic Pressure, or Wigand-A. Martin Method. (7) Jaw, Shoulder Traction, and 
Suprapubic Pressure, or the Combined Method. (8) Foot-and-shoulder Traction, or 
Prague Method, (p) Forceps for the After-coming Head. (10) Delivery of the Head in 
Persistent Sacro-posterior Cases. 

It should be remembered that in all breech cases delivery must be completed 
within five minutes of the emergence of the umbilicus, as the pressure exerted 
upon the cord will usually result in fatal asphyxia if continued longer than that 
time. It is also to be understood that during all these manipulations the body 
of the child is to be wrapped in hot. sterile towels, as diminution of the body- 
temperature is extremely dangerous. In the following descriptions the direc- 
tion of traction is described in relation to the long axis of the mother's body; 
thus, downward means toward her feet; backward signifies toward the floor if 
she lies upon her back. 

Dangers. — Traction upon the legs may cause separation of the epiphyses. 
Pressure upon the clavicles by the hand grasping the shoulders may fracture them 
and cause paralysis of the upper extremities by pressure upon the brachial plexus. 
Dislocation of the cervical vertebrae with laceration of the spinal cord is more 
likely to result from the use of the Prague method than from any other. Such 
traction may also cause laceration of blood-vessels and may result in hematoma 
of the sternocleidomastoid. The compression to which the cord is subjected, 
particularly in forceps delivery or birth of the head of a persistent sacro-posterior 
case, may cause cerebral hemorrhage or fracture of the skull. Traction on the 
jaw by the finger in the mouth may lead to dislocation. Misdirected force in 






EXTRACTION OF THE AFTER-COMING HEAD. 



1045 




Fig. 1194 



extractiox of 

Delivery of the 



the After-coming 
Posterior Arm. 



Head. 



bringing down an extended arm may cause fracture of the humerus, and at- 
tempts to cause rotation of the head by force exerted upon the trunk alone may 
dislocate the cervical vertebrae. 

1. Delivery of the Extended Arms (Figs. 1193 to 1199). — One arm or 
both may become extended from too energetic traction upon the body of 
the fetus in simple breech presentations, or this may occur during the 
necessary manipulations in the delivery of an impacted breech; and, 
indeed, without these 
causes the arms may 
become extended at full 
length, beside the child's 
head. Before delivery of 
the head is possible, un- 
less the child is very pre- 
mature, the arms must 
be brought into a nor- 
mal position. The pos- 
terior arm should first 
be manipulated, as the 
sacral hollow gives more 
room than there is ante- 
riorly. The child's legs 
being grasped by the 
operator's left hand just 
above the malleoli, its 
body is carried upward 
and flexed over the 
mother's right hip in 
left sacro-positions, and 
over the left hip in right 
sacro-positions (Fig. 
1 194). This moves the 
posterior fetal shoulder 
down into the pelvis. 
The operator's index 
and middle fingers of 
the hand whose palm 
corresponds to the dor- 
sum of the fetus are 
inserted into the vagina 
till the child's scapula is 
reached, and then along 
the back of the arm 
to the elbow, which is 
pulled forward into the 

sacral cavity so that the child's arm comes in front of its face 
finger through the elbow-joint and pulling downward the arm is flexed, and by 
extension the forearm is delivered on the chest of the fetus (Fig. 1196). The 
process is now reversed and the right hand grasps the fetal body and carries it 
over the mother's left thigh, etc., till the other arm is delivered. These manip- 
ulations must be conducted with great gentleness and care to avoid fracture 
of the humerus. 




Fig. 



1 195. — Extraction of 
Delivery of the 



the After-coming 
Posterior Arm. 



Head. 



By hooking a 



1046 OBSTETRIC SURGERY. 

Dorsal Displacement of the Arm (Fig. 687). — A far less common accident 

than simple extension is dorsal displacement of the arm. The arm is extended 
along the head, the elbow flexed, and the forearm behind the neck. This displace- 
ment may result from attempts to rotate the trunk or head, the arms not rotating 
with the body and so passing behind it. This constitutes a serious obstacle to 
delivery, as the forearm prevents the occiput from passing under the pelvic arch. 
It is overcome by rotating the body in the direction opposite to that which 
caused the displacement, thus bringing the arm in front of the fetal head. 
The extremity may then be drawn down, as in the case of simple extension 
of the arm above the head. If the occiput has been directed posteriorly by 
the manceuvers and fails to rotate forward at once after extraction of the arm, 
this should be brought about artificially in the following manner. 

2. Manual Rotation of the Transversely Placed Head (Figs. 1200, 1201).- 
When the head presses with its long diameter transverse or with the occiput in 




Fig. i 196. — Extraction of the After-coming Head. Delivery of the Poste- 
rior Arm. 

the sacral hollow, the head and trunk should be firmly held by the Smellie or 
Smellie-Veit grasp (see below), and rotated so as to bring the occiput to the front, 
when the delivery can be completed (see below). Rotation by grasping the trunk 
alone must be carefully avoided, as it is liable to cause injury to the spinal cord 
if the head fails to rotate at the same time. I have found that one finger in 
the child's mouth, the thumb, third, and fourth fingers over the shoulders, and 
the second and third fingers on the occiput is a very reliable method for head 
rotation (Figs. 1201, 1203). 

3. Uterine Compression (Fig. 1204). — When conditions arise that demand 
speedy delivery, it may be attained by suprapubic uterine compression. Uterine 
compression is of great value and power in expelling the head, as the force is ex- 
erted almost directly upon the head itself. Applied by a trained assistant, it 
may advantageously be combined with the Smellie or Smellie-Veit method. 

4. Face-and-shoulder Traction, or Smellie Method.— The operator's right 
or left hand is passed between the thighs and then between the arms of the 



EXTRACTION OF THE AFTER-COMING HEAD. 



1047 



child, whose body rests upon the forearm while the arms and legs hang down at 
each side. For face traction that hand should be chosen the palm of which 
naturally corresponds with the face 
of the fetus; thus, the right hand 
when the face looks to the left, and 
vice versa. The index and middle 





Fig. i 197. — Extraction* of the After- 
coming Head. Rotation of the 
Fetus ix Order to Brixg the An- 
terior Arm ix the Posterior or 
Roomier Segmext of the Pelvis. 



Fig. 119S. — Extractiox of the After- 
comixg Head. Delivery of the Arms 
ix the Sacro-posterior Position of 
the Fetus. 




Fig. 1199. 



-Extraction of the After-comixg Head. Delivery of the Arms in the 
Sacro-posterior Position of the Fetus. 



fingers of this hand enter the vagina and their tips are placed one at each side 
of the child's nose. The other hand grasps the shoulders from behind, the 



1048 



OBSTETRIC SURGERY. 



index-finger over one, the other three fingers over the other clavicle. The tips 
of these fingers first aid flexion of the head by pressing the occiput upward, 
while the fingers applied to the face of the fetus attempt to draw it down. 
When the head is well flexed, traction is made downward with both hands, the 
second grasping the shoulders as described. As soon as the occiput is well 
engaged under the pubic arch the body is raised over the mother's abdomen 







Fig. 1200. — Extraction of the After- 
coming Head. Manual Rotation of 
the Fetus in Order to Favor Ante- 
rior Rotation of the Occiput in 
Sacro-posterior Positions. 



Fig. 1201. — Extraction of the After- 
coming Head. Manual Rotation of 
the Transversely Placed Head. The 
upper figure shows the rotation com- 
pleted. 



while the fingers of the internal hand continue to exert traction, as those of the 
external do upon the shoulders. As the face emerges over the perineum the 
shoulder hand must leave the shoulders and protect the perineum by drawing 
the vulval tissues backward and toward the median line and by preventing 
sudden expulsion of the forehead. This method of traction is inferior to the 
following, also recommended by Smellie, because the fingers on the face of the 
child cannot secure a firm grasp upon the slippery skin for traction. It was sug- 



EXTRACTION OF THE AFTER-COMING HEAD. 



1049 



gested by him as avoiding danger to the jaw, which the Smellie-Veit method 
involves. 




Fig 1202. — Extraction of the After-comixg Head. Digital Flexion of an 
Extended Head Above the Pelvic Inlet. 




Fig. 1203. — Extraction of the After-coming Head. Digital Flexion of a Partially 
Extended Head at the Pelvic Inlet. 



5. Jaw-and-shoulder Traction, or Method of Smellie-Veit or Mauriceau 
Method (Fig. 1206). — This manoeuver differs from the last only in that traction is 
applied by the index-finger in the mouth instead of by two fingers upon the face. 



1050 



OBSTETRIC SURGERY. 



It affords a far more effectual grasp upon the face. Great care is necessary lest 
the lower jaw be injured by the use of excessive force. 

6. Jaw Traction and Suprapubic Pressure, or Wigand-A. Martin Method (Fig. 
1207). — The child's body lies astride the operator's right or left arm, as in the pre- 
ceding methods, while the fingers are inserted into the vagina, the index-finger 
being passed into the infant's mouth so that by traction complete flexion of the 
head may be secured. The fingers of the remaining hand are placed on the ab- 
domen over the occiput which lies just above the symphysis. By the combina- 
tion of the pressure above in the axis of the parturient canal and the traction be- 
low, the head is delivered. On the appearance of the head at the vulva the 




Fig. 1204. — Extraction of the After-coming Head. Suprapubic Uterine Compres- 
sion.— (From a photograph taken at the Emergency Hospital.) 



child's body is carried upward toward the mother's abdomen, which lessens 
the danger of perineal laceration. 

7. Jaw, Shoulder Traction, and Suprapubic Pressure, or Combined Method 

(Fig. 1208). — In difficult cases it is advisable to use a combination of the above 
methods, namely, the operator performs jaw-and-shoulder traction as in the 
Smellie-Veit method, while suprapubic pressure, as in the expression of the fetus, 
is performed by a competent assistant. 

8. Foot-and-shoulder Traction, or Prague Method (Fig. 1209). — One of 
the operator's hands grasps the child's feet from behind, the middle finger 
passing between the ankles. The other hand grasps the child's shoulders 
as in the Smellie method, and downward and backward traction is exerted 



EXTRACTION OF THE AFTER-COMING HEAD. 



1051 



by both hands till the perineum is well distended by the head. The hand 
grasping the shoulders is now used as a fulcrum around which the head 
is rotated by raising the body and lower extremities over the mother's abdomen 
while continuing to exert traction with the hand holding the ankles. This 




Fig. 



-Extraction of the After-coming Head. Face and Shoulder Traction 
Smellie Method. 



method involves the use of great force, which may cause dislocation or fracture 
of the neck or clavicles of the child, and should never be employed. 

g. Forceps for the After-coming Head. (See Forceps, page 1054). — This method 
is rapid and valuable and may be used when the other methods fail. The child's 
body is carried up over the maternal abdomen. The blades of the forceps are 




Fig. 1206. — -Extraction of the After-coming Head. Jaw-and-shoulder Traction. 
Mauriceau or Smellie-Veit Method. 



applied to the fetal head and delivery proceeds as in the usual forceps operations. 
It is used only after failure of manual extraction and never in cases with the 
head above the inlet. 

10. Delivery of Head in Persistent Sacro-posterior Cases (Figs. 12 10). — If 
manual rotation, as described above, of the head whose occiput fails to rotate 



1052 



OBSTETRIC SURGERY 




Fig. 1207. — Extraction of the After-coming Head. Jaw Traction Combined with 
Suprapubic Pressure. Wigand-A. Martin Method. 




Fig. 1208. — Extraction of the After-coming Head. Jaw, Shoulder Traction, and 
Suprapubic Pressure. The Combined Method. 



EXTRACTIOX OF THE AFTER-COMIXG HEAD. 



1053 





Fig. 



1209. 



■Extraction of the After-comixg Head. Sacro-posterior Position. 
Shoulder axd Leg Traction. Prague Method. 







■ 



/ 



' 






Fig. 



12 IO. EXTRACTIOX OF THE AFTER-COMIXG HEAD. PeRSISTEXT SaCRO-POSTERIOR 

Positiox. Jaw axd Shoulder Tractiox axd Extexsiox of the Fetus. 



1054 OBSTETRIC SURGERY. 

anteriorly is unsuccessful, the head must be extracted with the face anterior. 
This is accomplished in one of two ways : (i ) If the chin is caught above the sym- 
physis, traction upon the fetus should be directly forward toward the ceiling when 
the woman is in the dorsal position. External abdominal pressure is made down- 
ward and backward upon the head at the same time. The head rotates around the 
symphysis and the occiput is born first. (2) If the chin is below the symphysis, 
the woman is placed upon her back with the hips over the edge of the bed or 
table, so that traction can be exerted directly backward — toward the floor. The 
other hand presses downward upon the head above the pubis, and, if necessary, a 
finger in the rectum can further increase flexion of the head by pushing up the 
occiput. Jaw traction will also assist. By this method the face is born first. 
Method Advised. — As a general rule, preference should be given to the Smellie- 
Veit method, combined with suprapubic uterine compression by a trained assist- 
ant, or the Wigand-Martin method if unassisted and the Smellie-Veit fails. If 
these are not successful, the forceps must be rapidly applied, remembering that 
five minutes is the allotted time from the appearance of the umbilicus to the 
birth of the head. 



VII. THE FORCEPS. 

Historical. — This instrument in some form evidently dates back to some time before 
the Christian era, as crude patterns of it have been found in connection with archaeological 
investigations in Egypt and elsewhere. By reason of the complete silence of classical 
authors upon so important a subject as instrumental extraction of living children, it has 
been assumed that the forceps of that period was used only for the extraction of dead 
fetuses. Somewhere about 1600 it is believed that Peter Chamberlen, of London, began 
to use the forceps as a matter of routine in obstetrical practice. We do not really know 
when or by whom it was invented, nor how the inventor was influenced toward his inno- 
vation. It is certain, however, that the Chamberlens possessed a monopoly of the instru- 
ment, and that the secret was virtually preserved among the members and pupils of the 
family until the independent invention of a forceps by Palfyn in 1723, together with Chap- 
man's published description of Chamberlen's instrument in 1725, had made this discovery 
the common property of the profession. The Chamberlen forceps consisted of fenestrated 
blades joined to a scissor-like handle. The cephalic curve was admirable, but there was 
no pelvic curve, shank, or lock. After adaptation the blades were held in place by 
tape wound tightly between the handles and blades where the halves cross. The absence 
of pelvic curve and shank shows conclusively that the Chamberlens practised nothing but 
the low operation. After knowledge of the forceps had become the common property 
of the profession, but a few years elapsed before the good results of publicity became appar- 
ent. Levret, the leading obstetrician of his age and a man of mechanical genius, added at 
one stroke the pelvic curve, shank, and lock (about 1747). The modern long forceps has 
undergone but little alteration since his time. Smellie, his great British contemporary, 
devised the so-called English lock, but his chief service to midwifery lies rather in his dis- 
coveries concerning the mechanism of labor than in forceps construction. A century 
elapsed before the forceps underwent another revolutionary advance. The imperfection 
of forceps traction with the head at the brim appears to have been recognized during the 
first quarter of the nineteenth century, and attempts in the direction of axis traction were 
made by attaching traction cords, accessory rods, etc., to the blades of the high forceps. 
None of these devices was successful in making true axis traction, as the "line of pull " neces- 
sarily ran within the birth canal. The difficulty was overcome to a certain extent by using 
the high forceps as a lever with the hand as a fulcrum. Finally, in 1877, Tarnier intro- 
duced to the notice of the profession his axis-traction forceps which, in the opinion of most 
obstetricians, has permanently solved the problem of traction at the inlet. During the 
quarter century just elapsed there have been no advances in forceps construction. 

Description. — The forceps consists of two halves almost identical in con- 
struction. They cross like the branches of scissors and interlock, and are known 

as the arms. The left arm is the one which is held with the left hand and 
introduced into the left side of the pelvis and which contains the pin or 



THE FORCEPS. 1055 

screw of the lock. The right arm, which is introduced into the right side 
of the pelvis with the right hand, contains a notch for the reception of the 
pin or screw. Each arm of the forceps consists of a blade, shank, handle, and 
a portion of the lock. The blade is fenestrated to secure lightness, and its 
free extremity is termed the apex (Fig. 121 1). Solid-bladed forceps are pre- 
ferred by a few operators, but by most are used only for special actions, such 
as rotation (Fig. 12 16). Some authorities reject the solid blades as liable to 
slip over the head. The blade has a double curve, one being on the flat, 
which corresponds to the convexity of the fetal skull, the other on the edge, 
to conform to the curve of the pelvic excavation. These are known respec- 




Fig. 12 1 1. — The Forceps. The Left Arm is the One which is Held in the Left Hand 
and Introduced into the Left Side of the Pelvis. The Right Arm, which is 
Introduced into the Right Side of the Pelvis, is Held in the Right Hand. 



tively as cephalic and pelvic curves (Fig. 12 12). When the instrument is 
locked, the handles come together to form a single grip for the operator's hand, 
and several devices are added to increase the strength of the hold, such as expan- 
sion at both ends, and corrugation in the continuity (Fig. 12 12). The entire 
instrument should be constructed of well-tempered steel, which is also suitable 
for ready sterilization. In regard to correct proportions, the blades in position 
should be at least 3 inches (7.62 cm.) apart at the acme of the cephalic curve, and 
1 inch (2.54 cm.) apart at the tips. When the instrument lies upon its convex 
edge, the tips of the forceps should be 3^ inches (8.89 cm.) above the general 
level; in other words, the highest portion of the pelvic curve is at the tip. For- 



1056 



OBSTETRIC SURGERY. 



ceps having a short shank and no pelvic curve may be used for the low operation, 
but such a pattern is unnecessary, as the ordinary instrument with its double 
curve and longer shank can be used with equal readiness in any part of the 
pelvis. Of the innumerable patterns of forceps, the following are the most 
popular: Naegele and Breus in Germany (Fig. 1213); Tarnier in France (Fig. 
1 2 14); Simpson's in England (Fig. 121 2); Simpson, Elliott (Fig. 12 15), and 
Tarnier in America. 

Antero-posterior Forceps. — A French writer, Penoyee,* has devised a special 

form of forceps in which one blade has 
a much greater degree of curvature 
than the other, so that when applied 
at right angles to the plane in which 
the ordinary forceps is used the blade 
with the more marked curvature fits 
into the hollow of the sacrum, and is 
thus supposed to render delivery 
easier. It may, however, be pointed 
out that the difficulties which re- 
quire forceps delivery are encoun- 
tered not while the head is in the 
hollow of the sacrum, but at the 
superior strait and at the outlet, at both of which points the peculiar shape 
of this forceps is of no advantage. 

Straight Forceps. — Forceps without the pelvic curve have been made and 
recommended especially as rotators in occipito- and mento-posterior positions of 
the head. I have been unable to satisfy myself that as rotators they possess any 
advantages over the ordinary instrument. 

Axis -traction Forceps. — Since traction with the ordinary forceps when the 
head is high in the pelvis necessarily tends to pull the presenting part against the 
symphysis, numerous attempts have been made to overcome this difficulty. (1) 
Some obstetricians use one hand as a fulcrum for the shank of the forceps while 




Fig. 



1212. — -The Cephalic and 
Curves of the Forceps. 



Pelvic 




The Breus Forceps. 



the other hand seeks to tilt the fetal head into the excavation, in which situation 
it becomes amenable to ordinary traction (Pajot) (Fig. 12 17). These manceuvers 
are described in full under the high operation. (Page 1070.) (2) Another old 
method consists in attaching tapes, so-called traction strings, to the blades of the 
forceps, so that the traction force exerted by the operator would be more nearly 
in the axis of the birth tract (Poullet). (3) Still another device consists in using 
one arm of the forceps as a lever, the blade being passed between the fetal head 
and the symphysis, the latter serving as a fulcrum. A tape is attached to the 
blade, and while one hand makes the leverage the other performs traction (Fara- 

*" Revue Clinique dAndrologie et de Gynecologie," May 13 and June 13, 1895. 



THE FORCEPS. 1057 

beuf and Varnier). This principle, however, is best carried out by a traction 
rod attached to the blades of an ordinary long forceps which permits of automatic 
traction and leaves little or nothing to the judgment of the operator. The credit 
for the introduction of the accessory traction rod into obstetrics belongs wholly to 
Tarnier (Fig. 12 18). Owing to a sharp bend in the shank of the rod, the "line of 
pull" actually passes through the pelvic floor, although traction in this imagin- 




Fig 12 14. — Tarnier's Axis-traction Forceps. Latest Pattern. 

ary line is intended only to carry the head into the excavation. An ordinary 
long forceps furnished with a two-armed traction rod constitutes the axis-traction 
forceps as originally introduced by Tarnier. Numerous modifications of this 
principle are in use to-day. A further advantage of Tarnier's forceps is found in 
the movable joints formed at the insertion of the traction rod into the blades of 
the forceps, by virtue of which the blades are left free to follow the natural 
movements of the head (Fig. 12 14). 



Fig. 1215. — Elliott's Modification of Simpson's Forceps. 

Action of the Forceps. — The functions performed by the forceps comprise (1) 
traction, (2) compression, (3) rotation, (4) leverage, and (5) reflex stimulation of 
the uterus, or oxytocic action. This is the classification in vogue at the present 
day. Skutsch and a few other authorities would eliminate compression and 
rotation, so that, according to them, the instrument has but three distinct func- 
tions. ( 1 ) Traction, which is applicable to head and breech presentations only, and 
aids the natural forces of the uterus and abdominal muscles to expel the child. 
(2) Compression, enumerated among the functions of the forceps, is admitted to be 
67 



1058 



OBSTETRIC SURGERY. 



sl source of danger to the child and a meddlesome interference with head-mould- 
ing. For such a purpose it is never indicated, and its production is unintentional 
— an unavoidable evil. Only enough compression is indicated for the blades to 
hold firmly. In extracting, therefore, the instrument should be grasped near 
the lock, for if held by the tips of the handles the blades will be approximated to 
an unnecessary degree. This advice is especially to be heeded when the forceps 
is applied obliquely. The belief was formerly prevalent that in the application 
of forceps at the inlet compression was necessary to cause 
the engagement of the head. This originated from the 
fact that as the head entered the excavation the handles 
could be seen to approach each other, showing that the 
blades were compressing the skull. This explanation, 
however, is false. The head following the natural descent 
— even in the presence of the forceps — presents certain 
of its smaller diameters in succession, and the forceps in 
adapting itself to them causes the approximation of the 
handles. While slight forceps compression may be 
without effect on the fetal head, the results of forceps 
delivery in contracted pelves show that in most cases it 
causes a great variety of cranial and endocranial lesions, 
to say nothing of the part it plays in causing asphyxia. 

(3) Rotation is classed as a function of the forceps. While 
available in certain conditions (see treatment of occipito- 
posterior positions, page 1072) in the hands of an expert, it 
is a source of danger in other circumstances, menacing the 
maternal parts as well as the fetus. Many authorities 
eliminate it completely from the list of functions, stating 
that in the great majority of cases rotation is not an inde- 
pendent act but is brought about by simple traction. 

(4) Leverage was once applied more freely than at 
present. Its principal use to-day is in cases in which 
the head is advancing with unusual difficulty, when trac- 
tion may be varied by horizontal to-and-fro movements. 
The axis of the forceps should not depart more than 30 
degrees from the median plane of the pelvis. To-and- 
fro movements in the vertical direction are strictly con- 
traindicated, as the maternal passage may readily be 
injured. The movement of the forceps in delivering the 
head is not leverage but simple traction. (5) The oxytocic 
or reflex action of the forceps upon the uterus is manifest 
when the instrument is adjusted to the fetus after a 
period of uterine inertia. Even the application of a 
single blade may be sufficient to revive uterine action, 
and the uterus in some cases is sufficiently stimulated to 
finish the labor without further aid. If the blades are 

cold, the oxytocic action is still more marked. It is almost needless to state 
that no one ever applies forceps solely for the sake of stimulating the uterus. 

Classification. — The usual classification of simply high, median, and low 
operations is defective and unsatisfactory- for the student, since it confuses two 
very different operations, namely, the high and median, and takes no cognizance 
of the two widely differing varieties of the median operation, for in this last 
variety the presence of an undilated or unretracted cervix is'an element of great 



s 



Fig. 1216. — Hohl's 

SOLID-BLADED FoR- 
CEPS. 



THE FORCEPS. 



1059 




■ 1^ 



Fig. 12 i 7. — The Principle of Axis-traction Ap- 
plied with Ordinary Forceps. Pajot's Man- 
euver. 



importance in the prognosis and treatment. The classification adopted in this 
work is as follows: A high operation is one in which the presenting part is still 
above the pelvic inlet, a maximum circumference, such as the occipito-frontal 
in vertex presentations, not having passed the plane of the inlet. A median 
operation is one in which a maximum circumference of the presenting part has 
passed the plane of the pelvic inlet. We should recognize two important 
varieties of median operation; 
first, those cases in which the ring 
of the cervix has only partially 
retracted over the presenting 
part, the latter being practically 
within the uterine cavity (Fig. 
12 19); and, second, those cases in 
which complete retraction of the 
cervix over the presenting part 
has occurred, the head resting in 
the vagina below the ring of the 
cervix (Fig. 12 19). A low opera- 
tion is one in which the present- 
ing part is at or in the vulva. 

Frequency of Forceps Operations. — The proportion of cases in which delivery 
is completed with the forceps naturally varies in different clinics. During three 
years in the Paris Maternity (ending March 1, 1899) the forceps was applied 
236 times in 4380 deliveries, about 6 per cent., or 1 in 16.67. Of the 236 extrac- 
tions, 211 were examples of the ordinary low or median operation, while the 
remaining 25 were high- forceps cases, all for contracted pelves.* During one 

year at the Glasgow Maternity 
there were 187 forceps deliveries 
in 2179 confinements, about 8.5 
per cent., or 1 in 11.7. Of 482 
cases confined at the Maternity 
proper, there was 18 per cent, 
of forceps intervention, or 1 in 
5.5; while of 1697 women con- 
fined at their homes by the Ma- 
ternity staff, 6 per cent, were 
delivered by forceps, or 1 in 
16. 7. f During the year 1898 
there were 6 forceps deliveries 
in 458 confinements at the 
Brussels Maternity, only about 
1.3 per cent., or 1 in 774 
Ahlfeld (1897) reports 4000 
cases with no forceps opera- 
tions, or 2.75 per cent., or once 
in 36.3 cases. § In 2200 con- 
finements in two hospitals I found that the forceps was applied in 208 cases, 
or in 9.45 per cent, of all cases, or once in 10.5 cases. In the 208 forceps 

*Dubissy et Thoyer-Rosat: " Med. Moderne," April 12, 1899. 

t Black: "Trans. Glasgow Obstet. and Gynecol. Soc," vol. 1, 1896-9, p. 71, appendix. 

$ " Journ. d'accouchements," Feb. 19, 1899. 

I Ahlfeld: " Lehrbuch der Geburtshilfe," second edition, 1898, p. 508. 




Fig. 12 18. — -The Principle of the Axis-traction 
Forceps. A, The blade of the forceps applied to 
the fetal head at the pelvic inlet. B, The traction 
rod at right angles to the handle of the forceps. 
A, B, The direction of the traction. 



1060 



OBSTETRIC SURGERY. 



operations, I found 24 were high operations, 43 median, 123 low, and 18 had 
no record of the position of the head in the pelvis. 

Indications.— The question, "When is the forceps indicated?" is answered 
broadly as follows: It is to be used whenever labor is to be quickly terminated, 
whenever the life of the mother or child is in peril, provided that contraindica- 
tions are absent. The dangers to which the mother, child, or both are exposed 
must naturally be of the sort which are removed or diminished by the termi- 
nation of labor. When the latter is uncomplicated by any special condition 
like eclampsia or hemorrhage, the chief dangers are in exhaustion on the part 
of the mother and in asphyxia of the fetus; which is equivalent to stating that 
the anomalies of labor which require forceps are largely mechanical in character, 
and that therefore whatever imperils the mother by causing obstruction and 




Fig. 12 19. — Classification of Forceps Operations. High Operation. Median- 
Operation with Complete Retraction of the Cervix over the Presenting Part. 
Median Operation with only Partial Retraction of the Cervix over the Pre- 
senting Part. Low Operation. 



delay also endangers the fetus by compression of the cord, placenta, head, or 
chest. The said anomalies of labor which produce these effects in the mother 
and child are equivalent to dystocia, maternal or fetal. While it is seldom 
difficult to recognize the presence of maternal conditions which demand forceps 
intervention, it is by no means always easy to determine when the fetus is in 
peril. If the heart-beat either increases or diminishes steadily, evidence is thereby 
furnished of disturbance of the placental circulation, which means peril for the 
child. This behavior of the heart must not be confounded with the slight 
variations which occur during a uterine contraction. The presence of meconium 
in the amniotic fluid is dubitable evidence of fetal distress. In breech presen- 
tations it means nothing at all, for it is expressed from the anus mechanically; 
and even in head presentations its presence may be inconclusive. I have fre- 
quently seen healthy, unasphyxiated children born by the vertex after copious 



THE FORCEPS. 1061 

escape of meconium. (Compare Asphyxia, Part IX.) As other evidence of 
the fetal state is not forthcoming, we must place our sole reliance on the fetal 
heart. 

Special Indications. — Maternal exhaustion and fetal asphxyia are the general 
indications for forceps, but it is necessary to recapitulate the different forms of 
dystocia which tend to produce these conditions. The indications may proceed 
from anomalies of the expulsive functions, anomalies of resistance, certain 
presentations and positions of the child, and miscellaneous or non-mechanical 
complications of labor, (i) Anomalies of expulsive forces: Simple inertia with- 
out obstruction may require forceps. (See Part V.) Protracted labor without 
evidence of obstruction belongs here, but in the many cases of arrested labor 
with maternal exhaustion some mechanical hindrance is present, and therefore 
such cases belong in the next subdivision. (2) Anomalies of resistance : Rigidity 
and stenosis of the lower birth tract and contracted pelvis make up this category. 
If the natural forces cannot overcome the obstruction, the forceps is used unless 
contraindicated. (3) Fetal dystocia: Here belong such anomalies as occipito- 
posterior and deep transverse cranial positions, face presentations, arrest of 
after-coming head in breech cases, etc. (4) Miscellaneous: Here belong all 
severe non-mechanical complications of labor requiring its immediate ter- 
mination: Hemorrhage, rupture of the uterus, eclampsia, and accidental 
complications; severe acute or chronic disease occurring intermittently. But 
the use of forceps is not inevitable in these cases. In 208 high, median, and 
low forceps operations, I found the most frequent indications for its use were 
uterine inertia (75 cases); pelvic deformity (68 cases); persistent occipito- 
posterior position (41 cases) ; and to hasten labor in face and brow presentations 
and eclampsia. 

Prerequisites and Contraindications. — (1) The cervix must be fully dilated. 
If the os is but partly open, resort to forceps will mean extensive injury to the 
cervix both from the instrument when applied and from the head when it trav- 
erses the os. The lesions thus produced in the cervix may bleed profusely. 
If, however, there is a very urgent indication to end labor quickly, a narrow 
margin of undilated cervix may be incised or dilatation may be completed with 
the fingers as a preliminary to employing the forceps. (2) The membranes 
must be ruptured. If the forceps were applied to the head with membranes 
intact, the entire ovum would come away with probable detachment of the 
placenta. In delayed rupture it may be necessary to incise the membranes 
in order to apply the forceps. Cases may arise in which it is by no means easy 
to determine the condition of the membranes. Thus, a caput succedaneum 
may be mistaken for a bag of waters. The distinction is usually made by the 
presence or absence of hair, but in some cases it is necessary to use a speculum. 

(3) The greatest circumference of the head must have passed the inlet and the 
head must be fixed in the pelvis. A head movable at the brim constitutes a 
contraindication to the use of forceps. Such a head must either be made to 
engage by external manipulation or the labor must be completed by version. 

(4) Generally speaking, the forceps requires the presence of a due proportion 
between the head and pelvis. The latter must not be too narrow. A living 
child cannot be born in a pelvis with a conjugate of less than 2.95 inches (7.5 
cm.), and even in this degree of contraction a forceps could hardly be applied 
save to a very small and plastic head. Hence the conjugate should measure 
at least 3 inches (7.15 cm.). The forceps should not be applied to an over-large 
or hydrocephalic head, nor to an anencephalus. (5) The fetus should usually 



1062 OBSTETRIC SURGERY. 

be living if forceps is to be used. In case of a dead fetus perforation could be 
more safely done. 

Prognosis. — Very much depends upon the state of the mother at the time 
of operation. If the pulse is slow and full, the woman's condition may be 
pronounced good, even if the temperature is above normal. A rapid, low- 
tension pulse, on the other hand, is somewhat unfavorable because puerperal 
infection usually begins in this manner. Fetor of the vaginal secretions some- 
times announces the existence of sepsis developing intra partum. Before under- 
taking the high operation in contracted pelves we should examine the cervix 
in regard to the possibility of abnormal stretching, which may precede a rupture 
of the uterus. Whatever goes wrong in connection with forceps extraction 
will be laid at the door of the operator unless he informs the relatives in advance 
of the possibility of this or that accident. If a colleague is called in for con- 
sultation, he too should be fully informed in this respect. If the forceps is 
applied before the os is fully dilated, lacerations of considerable extent may 
occur in the cervix with more or less hemorrhage, which require suture imme- 
diately after delivery. Sometimes in the absence of complete dilatation a 
portion of the cervix is grasped in the forceps and torn of! during extraction. 
The vagina has been injured in many ways through use of the forceps. The 
posterior fornix has been perforated. In locking the blades a portion of vaginal 
mucosa may be included. The forceps very seldom contributes to the pro- 
duction of a vesico- vaginal fistula, which is generally due to the condition for 
which the instrument is applied. Contusions are caused by to-and-fro move- 
ments which are permissible only when lateral and of small excursion ; by forcible 
attempts at rotation; and, finally, by improper traction in the high operation. 
Slipping of the forceps is always a serious accident. It may result from incor- 
rect application of the blades or from uncontrolled traction. The perineum 
is always ruptured when the forceps slips in the low operation, and extensive 
lacerations of the vagina may result from slipping higher up. The majority 
of cases of acquired stricture of the vagina are due to forceps injuries. Improper 
traction is another source of maternal traumatism. The high operation occa- 
sionally gives rise to peroneal paralysis through compression of the lumbo- 
sacral nerve as it crosses the pelvic brim ; and among injuries to the bony pelvis 
which thus originate may be mentioned dislocation of the coccyx, rupture of 
the symphysis, and loosening of the sacro-iliac synchondroses. (Page 673 .) The 
various forms of traumatism which have just been enumerated are almost all 
preventable if the forceps is properly used. After forceps delivery there is 
more or less atony of the uterus with the likelihood of hemorrhage. When the 
child is extracted with forceps, the conditions are somewhat similar to those of 
precipitate labor, which perhaps explains the presence of uterine atony under 
these circumstances. For a consideration of the forceps injuries of the child, 
see sections on Fetal Birth Traumatisms, Asphyxia, etc. (Part IX, pages 878 
and 889.) I found in 208 forceps operations that 193, or 92.34 per cent., of the 
children were delivered alive; 11, or 5.26 per cent., were still-born; 1, or 0.47 
per cent., died in the puerperium, and there was no record in 4 cases (compare 
Version, page 987). Podalic version was attempted in one case of prolapsed 
cord. 

Preparation for the Operation. — The preliminary steps in a forceps inter- 
vention are antisepsis or asepsis, and the necessary arrangement of the patient 
upon a bed or an operating table. The indication for the application of forceps 
may arise so suddenly that but little time is available for preliminaries, which 



THE FORCEPS. 1063 

must therefore be quickly performed. Much of the antiseptic regimen should 
have been in force as part of the management of labor itself. The additional 
precautions are as follows: The forceps must be quickly sterilized by boiling, 
and if there is no time for this the forceps must be "fired" by being passed 
repeatedly through an alcohol name of sufficient size. This is readily accom- 
plished by saturating a small piece of absorbent cotton with alcohol and allowing 
it to burn on an ordinary dinner-plate. In a case of low operation in a multipara 
no other instrument will need to be sterilized. In case the obstetrician is not 
already prepared to meet post-partum hemorrhage and perform immediate 
suture of extensive lacerations, — and this lack of precaution is, of course, un- 
avoidable under many circumstances, — all the material requisite for such emer- 
gencies should be made ready and freshly sterilized. Vaginal disinfection, held 
by many to be undesirable in normal labor, is indicated in forceps extraction. 
Everything should be in readiness to reanimate a still-born child. The woman 
can be placed in the lithotomy position across the bed, but it is preferable in all 
operations to press into use the kitchen or other table and properly equip it 
with sheets, Kelly pad, and pail for drainage. The extremities may be held by 
leg-holders (Fig. 1022 ), by the sheet sling, or if necessary by assistants. The light 
should fall upon the vulva. The urine must be drawn with a sterile catheter, 
a somewhat difficult procedure when the urethra is compressed by the head in 
the excavation. If a catheter cannot be made to enter, it will be necessary to 
forego the act until after delivery. A suprapubic examination of the bladder 
should always be made, however, because if the viscus is distended it may 
simulate that thickening of the upper segment of the uterus which implies that 
the lower segment is thinned to the extreme. Such a condition of the uterus is 
produced in labor with contracted pelvis, and is a threat that rupture of the 
lower segment may occur. If the suprapubic tumor disappears when the urine 
is drawn, the operator need have no fear of this accident. If feces have accumu- 
lated in the rectum since the beginning of labor, they should be removed by 
an enema. In regard to anesthesia, it is hardly required in the low operation in 
multiparas. Aside from this, incomplete anesthesia may be recommended in 
easy extractions, and full surgical narcosis in all high and especially difficult 
cases. The anesthetic should be given by a colleague who has had experience. 
In rural practice the question of anesthesia is often very difficult to decide. 
There is no time to summon trained assistance, nor can the administration of 
chloroform be left to a novice. Under such circumstances the operator must 
choose between no anesthetic and partial anesthesia. In these cases when no 
assistant is at hand the woman should be etherized as deeply as appears neces- 
sary, and a novice quickly instructed in the use of the cone and the amount 
of ether to be used. An Allis inhaler is invaluable for such purposes. From 
the operator's position in front of the vulva the patient's face and respiration 
should be watched. Should cyanosis develop, he may be forced to leave the 
forceps, draw out the patient's tongue, and resort to the Sylvester method of 
artificial respiration. 

TECHNIQUE. 

Low Operation. — In extraction under the simplest circumstances with the 
head on the pelvic floor in the first vertex position, normal rotation having 
occurred, the technique is as follows : 

Introduction of the Left Blade. — The left blade is held with the left hand like 
a sword in fencing, with the thumb at the inner aspect of the handle, the three 



1064 



OBSTETRIC SURGERY. 





Fig. 1220. — The Correct Manner of Hold- 
ing a Blade of the Forceps. 



last fingers on the outer surface, and the index hooked over the flange-like 
projection at the distal end (Figs. 1220 and 122 1). The right hand assists the 
introduction by guiding the blade into the left side of the pelvis, and at the 
same time protecting the maternal and fetal structures (Fig. 1222). This work 
is done by the index and middle fingers introduced into the left side of the pel- 
vis as far as the child's ear and also paves the way for the forceps between the 
fetal and maternal parts. The thumb, strongly abducted, lies in front of the left 
labium majus. The handle is now elevated until it lies opposite the right groin 
and the tip of the blade is introduced into the vaginal entrance between the 

fingers of the right hand and the 

-" ~~ '" ^ fetal head, on the left side of the 

; v pelvis. The concave side of the 

blade is, of course, turned toward 
the fetus. The handle is now gradu- 
ally depressed until it is almost 
horizontal, and at the same time 
is carried somewhat toward the 
patient's left. This movement car- 
ries the tip of the forceps, protected by the two fingers, in a gentle curve 
about the head. The border of the forceps slides along the thumb, from 
which it derives its direction. 

Introduction of the Right Blade. — The right blade is introduced in the same 
way, except that the movements are reversed and that the presence of the left 
blade makes the introduction of its fellow somewhat more difficult. The utmost 
gentleness is to be used in the foregoing movements; force is not allowable. 
The right hand now holds the right blade while the first two fingers of the left 
hand are introduced into the right side of the pelvis preparatory to the intro- 
duction of the right blade (Fig. 1223). After the introduction of the right blade 
both blades are held for a moment by the right 
hand while the left hand is withdrawn from the 
vulva. If a blade cannot be introduced at first, it 
should be withdrawn and a second effort made. To 
facilitate the introduction of the right blade an 
assistant holds the handle of the left blade down 
and to the side. All efforts to introduce the blades 
should be suspended during a uterine contrac- 
tion. 

Locking. — After both blades have been properly 
introduced they should lock without difficulty. This 
is accomplished by taking a handle in each hand 
(Fig. 1224). Sometimes one blade is intro- 
duced further than the other, or the blades may 
not be exactly opposite each other, and slight move- 
ments of adjustment may be necessary. Difficulty 
in locking may indicate that the head has been 
seized transversely or obliquely, in which case the 
instrument should be removed and reapplied if pos- 
sible; or it may indicate some complication, e. g., an occiput posterior position 
or hydrocephalus. 

Test Traction. — The instrument is now grasped, the lock by the right hand 
with the thumb underneath and the middle finger in the angle of the two blades 
(Fig. 1225). The left hand is now placed across the right at a right angle, with 



^SssaJSi^ 




Fig. 122 i. — Incorrect Man- 
ner of Holding a Blade 
of the Forceps. 



THE FORCEPS. 



1065 



the left index finger pointing forward at the site of the small f ontanelle ; in this 
position gentle trial tractions are begun. The finger against the fetal head in- 
forms us whether the fetus follows the traction and also detects slipping. 

Method of Making Traction. — Tractions should be made by the use of the 
arms and forearms, never by the weight of the body (Fig. 1226). They should 
be made in imitation of nature during the pains, or, if these are absent at regu- 
lar intervals, they should be intermittent, each traction lasting not more than 
one minute. The aim should be to cause intermittent, alternate advance and 
recession of the head, as in natural delivery. All haste and excitement should 
be avoided. During the intervals between the tractions the handles should 
be loosened in order to limit the compression of the fetal head. 

Direction of Traction. — In every case the presenting part should conform 
with the mechanism of labor. The traction should be downward until the ex- 
ternal occipital protuberance is beyond the symphysis pubis. It is then made 




._._-*«»1k13!'.' . — , — — ~~™«»^ 

Fig. 1222. — Introduction of the Left Blade of the Forceps. 



in a forward direction, and as the occiput becomes visible it is gradually changed 
until the handles are brought directly upward (Figs. 1227 and 1228). 

Extraction of the Fetus. — When the small f ontanelle is visible, the left hand 
is removed from the right in order to protect the perineum. Traction is con- 
tinued until the nuchal region is in relation with the pubic arch; this contact 
being determined by the distance between it and the fontanelle. At this 
stage of expulsion the right hand raises the handle until it almost rests upon the 
abdomen and the head is born. The blades are now separated by the fingers. 
It is usually advisable to remove the blades before final expulsion of the head 
in order to lessen the stretching of the vulva and the risk of laceration (Fig. 1229). 
The mechanism of labor may be aided during perineal dilatation by alternately 
flexing and extending the head with the forceps, the handles being depressed 
just as the external occipital protuberance clears the pubic arch in order to 
produce complete flexion. The head may then be delivered at the pleasure of 
the operator, or whenever he may think that sufficient perineal dilatation has 
been secured. When the head is about to be delivered, many prefer to remove 



1066 



OBSTETRIC SURGERY. 



the delivery without it. This is advisable if the 
g., in primiparas. If the forceps is removed too 



the forceps and complete 

adaptation is very close; e 

soon, the head is apt to slip back into the vagina. Many authorities advise the 

introduction of the finger into the rectum in order to catch the child by the 

chin, but it is better to keep the head in place when possible by pressure upon 

the fundus or with a finger on each side of the coccyx (Fig. 624). Intrarectal 

manipulations are always to be avoided as far as possible, since they are not 



ASSISTANT 




Fig. 1223. — Introduction of the Right Blade of the Forceps. 



conducive to asepsis, and even a careful use of this method may injure the eyes 
of the child. 

General Principles. — The left blade is applied first because of the construc- 
tion of the lock. Two fingers suffice for guiding the forceps only when the head 
is very low and when the margin of the os cannot be felt ; otherwise four fingers 
should be employed. Great care is requisite lest the cervix be mutilated in the 
grasp of the forceps. While the fingers guide the forceps in front, the thumb 
performs the same function from the rear. Naturally an attendant could be of 
assistance in the introduction of the instrument. All force is contraindicated 



THE FORCEPS. 



1067 



in the introduction of the blades. At times there is difficulty in locking the 
instrument because the handles are not in the same plane. If the deviation is 
slight, they may be depressed a little, locked, and then elevated; but if it is 
considerable, it is evidence that at least one blade has not been properly intro- 
duced. In ideal forceps delivery the blades should be adapted to the convexity 
of the parietal bone. Under these circumstances the handles are almost per- 
pendicular to the sagittal suture. When they stand apart and cannot be locked, 





Fig. 1224. — Locking the Blades of the Forceps. 





Fig. 



-Test Traction. 



Fig. 1226. — Method of Making Trac- 
tion in Anterior Positions of the 
Vertex. 



an effort should be made to determine which blade is at fault by comparing the 
direction of the handle with the suture. The difficulty detected, the blade 
must be readjusted, but it is not always necessary to remove it. If simple 
traction with the hand crosswise over the lock is ineffective in moving the head, 
light lateral movements, to-and-fro, may be made. If this is unsuccessful 
traction may be made with both hands. Care must be taken not to compress 
the handles, for this means compression of the fetal skull. The direction of the 
traction should always be so ordained that the head describes movements 
identical with those of natural labor. We must not attempt to use the forceps 



1068 OBSTETRIC SURGERY. 

as a lever at the time of the expulsion of the head ; the handles should be raised 
during gentle, steady traction. To apply the principle of the lever would be to 
brace the forceps against the symphysis, which has been known to lacerate the 
venous plexuses by the side of the clitoris, while at the same time the pos- 
terior margin of the blades may cut the posterior wall of the vagina. The for- 
ceps occasionally slips or even comes entirely off. This may occur in two 
forms: (i) Horizontal, (2) perpendicular. In the former the blades slip over 
the sinciput or occiput, while in the latter the tips of the blades are pulled across 
the head in the line of pull. When the hands are crossed over the lock of the 
forceps, the index of the left hand is able to estimate the relations between the 
pull and the advance of the head. 

Median Operation. — Here, since rotation of the head has not occurred, the 
sagittal suture lying in an oblique pelvic diameter, there are two methods of 
operating. First, the forceps blades may be applied with relation to the sides of 
the pelvis only, — this is the pelvic application (Figs. 1230, 1222); second, they 
may be made to correspond or adapt themselves to the sides of the fetal head, 



Fig. 1227. — Direction of the Traction ix Anterior Positions of the Vertex. 

— this is the cephalic application (Figs. 123 1, 1232, 1233). The latter procedure 
or adaptation of the forceps should always be aimed at, and, after practice and 
attention to the mechanism of labor, can always be accomplished. Cephalic 
application secures a better prognosis for both mother and fetus by lessening 
the amount of traction necessary for extraction, the amount of pressure to 
secure a firm hold on the presenting part, and the danger of ruptures in the 
genital tract. 

Cephalic Application (Figs. 1231, 1232, 1233). — The preferable method 
is to apply the blades to the sides of the head, thus making compression 
in the biparietal diameter, where it does the least harm and where the least 
room is required for the blades, and more closelv imitating the natural mechan- 
ism of labor. If the occiput is to the left and 'anterior, the fingers of the right 
hand are passed into the vagina through the cervix if it has not completely re- 
tracted, and the left blade is passed under the guidance of the left hand well up 
into the space between the head and the left sacro-iliac synchondrosis, and held 
there by an assistant. The right blade is now passed up in the same manner 



THE FORCEPS. 



1069 



between the head and the right side of the pelvis wherever there is the most room. 
This will usually be near the right sacro-iliac synchondrosis. It is then gently 
urged forward along the right lateral wall of the pelvis until it occupies a posi- 
tion near the obturator foramen opposite its fellow or over the right ear of the 
fetus. This may be done by means of the fingers in the vagina, by depressing the 
handle, rotating it on its long axis and carrying it to the left (Fig. 1231). 

This is termed adaptation of the forceps to the biparietal diameter of the fetal 
head. The second method — namely, the pelvic application — is perhaps the safest, 
especially for beginners. If the cervix is not completely dilated, it should be digi- 
tally dilated, and care must be taken, in guiding the tips of the blades through the 




Fig. 1228. — Faulty Direction of Traction in Vertex Presentation. 



cervix and in bringing the right blade forward, that its concavity is carefully left 
in contact with the fetal head. The blades now hold the head in its biparietal 
diameter and tractions are begun. Artificial rotation is usually unnecessary, 
and should be avoided by beginners. Traction should at first be somewhat 
downward and backward according to the height of the head; the operator 
endeavoring to make traction with reference to the axes of the different pelvic 
planes through which the head must pass. If the head is in the upper part of 
the cavity, it may be easier to pass the anterior blade first, as in the high 
operation. 

Pelvic Application (Figs. 1230, 1232). — In this case the forceps is applied as in 
the low operation and the head is seized with one blade over the temple and the 



1070 



OBSTETRIC SURGERY. 



other over the parietal protuberance of the opposite side. After the head has ro- 
tated the forceps is removed and reapplied to the sides of the head. If the handles 
are loosely held, the head may rotate between the blades. During the passage 
of the head through the cervix undue haste must be avoided and the head allowed 
to advance and recede in imitation of the natural process of dilatation. A finger 
placed upon the cervical margin from time to time gauges the amount of tension. 
A finger between the head and the symphysis pubis will also show how much 
force is wasted in pulling against the symphysis. It should be the aim of the 
operator to keep the head closely applied to the anterior pelvic wall, but with- 
out pressing it against the symphysis. The operator should loosen his grasp 
occasionally during a pain and see that he is not opposing rotation. The direc- 
tion taken by the handles during a pain may serve to guide him. If the head 
is in the upper part of the cavity, the axis-traction forceps should be preferred, 

its skilful use improving the prog- 
^ nosis for both mother and child. If 

only the ordinary forceps is at hand, 
good results can usually be ob- 
tained, and one hand may be used 
as a fulcrum in the manner de- 
scribed in the high operation (page 
1070). In case of disproportion in 
size between the head and the upper 
part of the pelvis, the Walcher posi- 
tion will be of service in increasing 
the conjugate diameter and aiding 
engagement (page 937, Part X). 

High Operation. — This opera- 
tion should invariably be done 
under anesthesia. The patient is 
put in the exaggerated lithotomy 
position on a table of sufficient 
height. The operator is at a great 
disadvantage if the level is low, be- 
cause in making the necessary 
downward traction he would be 
compelled to kneel. The buttocks 
should be at the edge of the table. 
Ordinary Forceps. — The operation is performed with the ordinary forceps as 
follows : The blades should be applied in the transverse diameter of the inlet, there- 
fore at the occiput and sinciput respectively, for the head at the brim should usu- 
ally not be seized otherwise. The left blade is introduced in the hollow of the right 
hand into the left side of the pelvis, and adapted by the aid of the fingers to the 
fetal head, great pains being taken to prevent the inclusion of the thin margin of 
the dilated cervix. The right blade is then introduced in similar fashion and the 
instrument is locked, strong pressure being made at the same time against the 
perineum. A trial traction is first made to see if the hold is satisfactory, the 
forceps being grasped over the lock by both hands, the right overlapping the first 
two fingers of the left (Fig. 1225). While the left hand makes traction in the 
direction of the handle, the right presses vertically downward over the lock (Fig. 
121 7 ). As a result the head is drawn past the brim. The pressure upon the lock 
is not transmitted to the head as such, but the right hand forms a fulcrum for 
the lock of the forceps and the action of the left hand carries the handle upward 




Fig. 1229. — Removal of the Blades of the 
Forceps, after Delivery of the Head. 



THE FORCEPS. 



1071 




Fig. 1230. — Pelvic Application of the Forceps, a, a', 
Pressure exerted by lower edge of the right blade upon 
the fetal skull; b, b', pressure exerted upon the fetal skull 
by the upper edge of the left blade. 



and the blades and fetal head downward into the pelvis. Traction should not be 
prolonged over a minute, and after every second traction an examination should 
be made. The fetal heart should also be watched, and if fetal death occurs the 
forceps should be detached and the head perforated. As the head enters the 
pelvis the handles of the 
forceps are seen to rise. 
An examination should 
now be made to determine 
the position of the head 
and whether or not rota- 
tion has begun. If the 
head is turning, the han- 
dles are seen to approach 
each other. If, on the 
other hand, the head is 
still transverse, careful 
and slight anterior rota- 
tion of the occiput may 
be favored with the for- 
ceps. The head is then 
examined again. As soon 
as rotation is apparent, I 
advise in all cases removal 
and adaptation of the for- 
ceps to the sides of the head. The head may still persist in its high trans- 
verse position, and in that case the blades must be reapplied obliquely. It is 
not necessary to detach them, for each blade controlled by the finger may be 
slipped along the head to the locality desired. This accomplished, traction is 

made, while at the same 
time the occiput is ro- 
tated forward. The op- 
eration as described is 
very difficult, especially 
if the degree of pelvic 
contraction is consider- 
able. The obstetrician 
may be compelled to use 
the entire strength of 
both arms. Excessive 
force, however, is to 
be deprecated, for the 
strength of one man is 
the limit in this direc- 
tion. If still more force 
is necessary to pull the 
head into the pelvis, 
fracture of the cranial 
bones or intracranial 
hemorrhage will be certain to occur. If traction is made in the direction of the 
handles without depressing them, the force thus misdirected does not advance 
the child, but does make injurious compression on the anterior wall of the pelvis. 
Axis-traction Forceps. — On account of the difficulties connected with the high 




Fig. 1231. — Cephalic Application of the Forceps, or 
Adaptation. b, Left blade. The right blade is intro- 
duced opposite the right sacro-iliac synchondrosis at a, 
and carried with the internal fingers to a' . 



1072 



OBSTETRIC SURGERY. 



operation, axis-traction forceps has been used extensively for this purpose. 
They are described on page 1056. Aside from the special axis-traction apparatus, 
the instrument is simply an ordinary long forceps and is applied and locked in the 
manner just described. Traction, however, is made exclusively by the accessory 
apparatus until the head has been brought within the pelvis, the ordinary handles 
serving as a mere indicator which informs us as to the position of the head. After 
the latter is in the excavation the traction rod is disconnected and the child is ex- 
tracted with the forceps proper. 

Occipito-posterior Positions. — The forceps is indicated in occipito-posterior 
positions only when the life of mother or child is threatened. The application of 
the forceps in these cases is much more difficult than in the physiological cranial 
positions. As the parietal eminences are seated somewhat more deeply than 

in the latter, the handles of the forceps 
are more nearly vertical when the blades 
are applied. 

(1) In high cases. (The treatment of 
occipito-posterior position is used, page 
600, Part V.) 

(2) In medium cases. Should assist- 
ance be needed, the forceps will be called 
for. The head being well engaged, I am 
accustomed always to use the cephalic 
application of the instrument, namely, 
adapting the blades over the fetal ears. 
When the forceps is to be used as a ro- 
tator, the cephalic in preference to the 
pelvic application should always be aimed 
at, as the prognosis for both fetus and 
maternal soft parts is more favorable. 
Downward traction should then be made 
in the proper axis until the head is 
brought to the pelvic floor. If in its 
descent there is a tendency on the part of 
the occiput to rotate about the shortest 
segment of the pelvis to the pubis, this 
rotation should be encouraged, but no 
marked rotation with the forceps as 

rotator should be made until the head has reached the levator ani muscle. An 
excellent instrument for this class of cases as well as the high ones is the last 
model of the Tarnier axis-traction forceps. The forceps is applied reversed; 
namely, with the concavity of the pelvic curve toward the posterior part of 
the pelvis, and, of course, toward the occiput. Leaving the handles to take 
care of themselves, traction is made upon the traction rods only, and the swivel 
connecting these with the blades will allow of spontaneous rotation on the part 
of the head during its descent. Ordinary fenestrated or solid-bladed forceps 
will usually answer quite as well as the axis-traction ones. 

(3) In low cases. In operating, the usual conditions preparatorv to any for- 
ceps operation should be fulfilled, and straight, fenestrated, or solid-bladed forceps 
may be used. I have used both the fenestrated and the solid-bladed forceps, and 
find that the latter has certain advantages in ease of application, rotation, and 
safety to the maternal soft parts not possessed by the former. This is particularly 
true of difficult cases. The straight forceps with no pelvic curve, such as Taylor's, 







Fig. 1232. — Pelvic Application of the 
Forceps. 






THE FORCEPS. 



1073 



is not necessary for the success of the operation. When the occiput is directly 
toward the sacrum and not opposite either synchondrosis, I am accustomed to 
reverse the forceps, applying it 
upside-down, so to speak, with 
the lock down and pointing to the 
occiput. In all cases adaptation 
of the instrument renders the 
prognosis more favorable for 
mother and fetus. The forceps 
being properly applied, our ob- 
ject should be always to keep the 
points of the instrument in as 
nearly the center of the pelvis 
as possible; always to combine 
rotation with downward trac- 
tion; to rotate only in a very- 
small segment of a circle during 
one traction; and. if uterine con- 
tractions are present, to time the 
combined traction and rotation 
with uterine action. During the 
intervals of uterine contractions 
the head should be held in the 
position obtained in order to 
allow the fetal body time to ro- 
tate also and accommodate itself 
to the new position of the head. 
Bod5 r rotation can be confirmed 
by abdominal palpation. In my 
experience abdominal palpation 
with a view to assist body rota- 
tion is of little, if any, advantage. 
If the forceps has not been re- 
versed after the occiput has been 
rotated into the anterior segment 
of the pelvis, it will be necessary 
to remove and reapply the in- 
strument if delivery is to be ter- 
minated at this time, which is the 
wisest course to pursue. If the 
forceps was originally reversed, 
this removal and readjustment 
is, of course, unnecessary. 

Forceps as R otators ( Fig. 1235). 
— Much controversy has arisen 
over this question.* Many au- 
thorities claim that the produc- 
tion of rotation of the head by 
instrumental means through an 
arc of 180 degrees or even 90 degrees is attended by so much danger of 
producing lacerations of the maternal soft parts and injuries to the fetal head 

* Compare treatment of persistent occipito-posterior position, page 600. 
68 




Fig. 1233. — Cephalic Application of the For- 
ceps, with the Blades Adapted to the Sides 
of the Fetal Head in the Left Oblique Pel- 
vic Diameter. 




Fig. 1234. — Cephalic Application of the For- 
ceps, SHOWING THE BLADES ADAPTED TO THE 

Sides of the Fetal Head. 



1074 



OBSTETRIC SURGERY. 



or neck as rarely to be justifiable. A careful study of the subject, and espe- 
cially of the value of adaptation of the forceps to the sides of the fetal head, 
will convince any unprejudiced operator that with care and due regard to the 
mechanism of labor the operation is quite safe for both mother and fetus. 
For ten years the author has been using straight, fenestrated, and solid-bladed 
forceps as rotators in occipito-posterior cases, in tardy rotation of the head in 
vertex and face presentations, and of the after-coming head in breech extractions, 
and he sees no reason to abandon the procedure. The requirements for a good 
result in instrumental rotation are: (i) An accurate diagnosis of the presenta- 
tion and position, obtained under anesthesia and by the introduction of the 
whole hand if necessary. (2) The cephalic application or adaptation of the 
forceps blades to the side of the child's head as early in the operation as pos- 
sible. (3) A close imitation of the normal mechanism of labor in the casein 
question. (4) The combination of rotation and downward traction at one and 
the same time. (5) Most, if not all, of the rotation should be performed after 
the lowest portion of the presenting part has reached the pelvic floor, as in 
spontaneous rotation. 

Pelvic Presentations. — Skutsch does not even dignify this use of the forceps 
with a paragraph in his recent voluminous work on obstetric operations. Most 





II 



III 



Fig. 1235. — Rotation with the Forceps. The head in I lies transverse in the pelvis, 
with the occiput (0) to the left. The forceps is applied in the left oblique pelvic diam- 
eter, and the head is rotated (II, III) from left to right until the occiput (o) is anterior 
(III) and the forceps in the right oblique pelvic diameter. 



authorities, however, continue to recommend it in certain conditions. Forceps 
appear to be indicated in breech cases before it is possible to use the finger or a 
fillet to produce traction. Jewett recommends Olliver's axis-traction forceps. 
If the breech is fixed transversely in the pelvis, the blades should be applied over 
the trochanters. Pressure over the iliac crests is held to be dangerous and, 
generally speaking, the entire procedure is calculated to cause more or less in- 
jury to the fetus. As the hold cannot be very firm, traction must be slight and 
made only during pains, assisted by manual compression of the fundus. In my 
experience fetal traumatisms are frequent. 

After-coming Head (Figs. 1236, 1237). — The application of the forceps to the 
after-coming head, formerly much in vogue, has been displaced gradually by 
various methods of manual extraction, which, being capable of continued im- 
provement, have greatly benefited the chances for survival of the child. Therefore 
it is not surprising that many obstetricians advise doing away with instru- 
mental, delivery in these cases altogether. A majority, however, are in favor 
of using the forceps in certain cases, although the indications appear to be 
much confused in most standard books. The forceps is indicated in but a very 
small proportion of cases of after-coming head. It is positively contraindicated 
when the head is above the brim, for if manual extraction is unsuccessful the 



THE FORCEPS. 



1075 



head will probably have to be perforated, since the child will almost certainly be 
dead. The indications for the forceps are three in number, (i) The head is in 
the excavation with its long diameter antero-posteriorly or oblique, and, man- 
ual procedures having failed, immediate delivery is necessary to save the child's 
life. Experience has taught me that now and then a fetal life may be saved. 
(2) In abnormal rotation with the head extended, the face in front, and the chin 
over the symphysis. (3) In cases in which prolonged traction on the trunk 
threatens to rupture the child's neck. Such an accident might readily occur in 
a fetus long dead or in the presence of some disease. If the head is thus left 
behind, we have the condition known as detached head, to be described later. 
Technique: The general rule in vertex anterior cases is to apply the forceps 
below the child, which is lifted upon the mother's abdomen by the legs, care 




(J 



Fig. 1236. — The Forceps Applied to the After-coming Head in a Sacro-anterior 

Position. 



being taken not to stretch its neck. The arms are raised with the trunk; 
the forceps is applied in the usual manner, care being taken not to grasp the 
cord. Traction should be made in the direction of the handle until the chin 
appears. Thereupon the nuchal surface of the child should be made to rotate 
beneath the pubic arch, the handles being turned toward the mother's ab- 
domen. I am accustomed to apply the forceps above the child in occipito- 
posterior positions, while others simply advise that the instrument be applied 
in the easiest manner possible and independently of set rules. Detached head: 
In breech extraction the head may be detached and left in the uterus by accident 
or design. In the former instance the mishap arises from decapitation of the 
dead child as a result of too forcible traction. In the latter case the head is left 
after deliberate decapitation. If attempts at manual extraction fail, the forceps 



1076 



OBSTETRIC SURGERY. 






may be applied, although cephalotripsy, if available, is the more rational 
course. 

Face Presentations (Fig. 1238). — The general principle in the management 
of these cases is expectancy. There is no indication, from the position alone, 
to apply the forceps. Only when the life of mother or child is threatened should 
we resort to instrumental intervention. In mento-anterior positions with the 
face in the antero-posterior diameter, extraction should be easily effected. The 
handle of the forceps should be higher than in cranial occipito-posterior posi- 
tions. If this point is overlooked, the tips of the forceps may compress the fetal 
neck. Traction should be made in the direction of the handle until the chin is 
born beneath the symphysis, the child's throat being in contact with the liga- 
mentum arcuatum. The handle is now turned strongly upward toward the 







\i 







Fig. 1237. — The Forceps Applied to the After-coming Head in a Sacro-posterior 

Position. 



mother's abdomen, and the face, brow, vertex, and occiput are born in suc- 
cession over the perineum. The forceps carries the head from its position of 
extreme extension to one of flexion. As the handle of the instrument arrives 
at the abdomen the task is finished and the forceps should be detached. If 
the mento-anterior face is in an oblique diameter, the forceps is applied trans- 
versely unless the obliquity is extreme. Then, under traction, the head rotates 
normally. The oblique application is not contraindicated. In the second 
facial position, chin to the right, the left blade should" be applied in front; in 
the second, chin to left, the right blade goes in front. In a deep transverse 
facial position the forceps is applied obliquely with the pelvic curve turned 
toward the chin. The conditions are analogous to forceps delivery in deep 
transverse head (page 1077). Mento- posterior position: In mento-posterior 



THE FORCEPS 



1077 



positions with the indication for immediate extraction the forceps is of no 
service and the head must be perforated. Scanzoni's method of rotating 
the head with the forceps must be condemned. Some obstetricians hold that 
the manceuver may be feasible in some cases in the hands of an expert, but it is 
rarely safe. The head is grasped at the sides, the forceps being applied obliquely 
with the concavity of the pelvic curve directed in front. The face is now rotated 
into the transverse position. The blades are then detached and reapplied in the 
manner described for deep transverse face. (Compare Treatment of Mento- 
posterior cases, Part V, page 605.) 

Brow Presentation. — The forceps should be applied as in bregma and face 
presentations with the handles relatively high in order to obtain the best possible 
grasp of the head. In making traction we should always be controlled by knowl- 
edge of the mechanism in these cases. \Ye should pull in the direction of the 
handles until the root of the nose arrives at the ligamentum arcuatum. The 




Fig. 123S. — Forceps in Face Presentation. Mento-anterior Position. 



handles are then lifted well up and carried to the mother's abdomen, while the 
vertex and occiput are born over the perineum. The handles are then brought 
down again, pressure being made at the same time with the hand on the brow, 
and the remainder of the face is delivered. There is therefore an analogy, from 
the standpoint of forceps delivery, between brow and occipito-posterior positions. 
Deep Transverse Head. — There is no indication for the use of instruments 
in this position save immediate danger to mother or child. The forceps, in order 
to grasp the head over the parietal eminences, would have to be without pelvic 
curve (straight forceps) . If the ordinary instrument is used, the blades must be 
applied in an oblique diameter and the concavity of the pelvic curve must be 
turned toward the occiput. The latter is then rotated forward till the concavity 
of the forceps is turned to the anterior pelvic wall. If the occiput was on the 
left side of the pelvis, it rotates into the L. O. A., and vice versa. When the 
head is ready for extraction, the concavity of the side of the forceps must corre- 
spond with the curvature of the pelvic canal. Occasionally it happens that the 
mere locking of the forceps produces some rotation forward of the occiput, so that 
when the blades are brought into the transverse diameter the sagittal suture 



1078 



OBSTETRIC SURGERY. 



is found to be in the antero-posterior diameter. In this case as soon as the 
neck of the child reaches the pubic arch the handle is brought upright in the cus- 
tomary manner. If the small fontanelle is not brought to the. middle line when 
the blades are in the transverse diameter, extraction must be accompanied by a 
slight degree of rotation. 



VIII. THE SLING OR SOFT FILLET. 

The sling, soft fillet, noose, fillet, or loop, as it is variously called, is occasion- 
ally used in obstetric manipulations, and could, I am certain, with advantage be 
much more frequently employed. 

Indications and Actions. — The sling is used chiefly in cases of high arrest of 
the breech, and it should be noted that it has five distinct uses: viz., (i) As a 
tractor; (2) to prevent recession of the presenting part; (3) to facilitate manipu- 
lations by drawing the presenting part to one side; (4) to serve as an accessory 




_ 




Fig. 1239.— Method of Adjusting a Sling to the Foot. 

when the simultaneous employment of both hands is forbidden by lack of space ; 
(5) to prevent extension of the arm or arms. 

Material and Carriers. — A yard of two-inch gauze bandage boiled and mois- 
tened with 1 per cent, lysol solution answers very well for a soft fillet. Another 
excellent fillet is a yard of one-fourth-inch rubber tubing through which a tape 
is passed, stitched to the side of the tubing, and allowed to project six inches at 
both extremities. In many cases fillets can be passed over the thigh with the 
index-finger. This will often necessitate the passage of the whole hand into the 
vagina. A ready method is to take a No. 1 6 English catheter with stylet in place, 
and bend the end of the' catheter into a hook of the shape of the ordinary 
blunt hook (Fig. 11 18). A doubled piece of tape or bobbin is threaded into the 
edge of the catheter by means of the stylet, and the hook with the tape is passed 
over the thigh in the most convenient manner. The tape is then caught with 
two fingers or a pair of dressing forceps and the catheter withdrawn. The tape 
is now used as a sling to draw the desired fillet into position. Blunt hooks are 



THE FORCEPS. 1079 

often perforated with an eye at the extremity and used instead of the catheter. 
A fillet carrier or porte-fillet is a special instrument made for the purpose. It 
is on the principle of Bellocq's cannula used by surgeons in drawing a plug up 
into the posterior nares. It is curved like the obstetric blunt hook and has a 
long piece of whalebone running through the canal. 

In Pelvic Presentation. — Here the soft fillet is used as a tractor. In low arrest 
of the breech the hand usually proves the best tractor, and even in high arrest 
it is sometimes possible to pass a finger or several fingers into the flexure of 
the groin; when the hand cannot be used, we resort to the soft fillet or forceps. 
Traction with a single or double fillet, in impacted pelvic presentations, is a valu- 
able means of extraction, much safer in the hands of most operators than the 
blunt hook or forceps, and a method of delivery, I believe, too seldom resorted 
to. Often in tardy breech expulsion the delay is caused by flexion of the fetal 
pelvis upon the trunk, and perhaps by extension of the legs alongside of or above 
the fetal head. Traction on one or both groins extends the pelvis, draws down 
the feet, and thus renders the passage of the breech through the parturient canal 
easier, provided no great disproportion exists between fetus and maternal 
pelvis. Sling to one groin: When a single sling is used, it should encircle by 
preference the anterior or lower thigh, and in the majority of cases a single sling 
is sufficient. I have in difficult cases combined the sling to the anterior groin 
and the protected blunt hook to the posterior (Fig. 1187). Sling to both groins: 
Unless too great difficulty is encountered it is preferable to pass a soft fillet over 
both groins, as by so doing the force of traction is more evenly distributed and 
there is less danger of injury to the soft parts and the heads of the femurs. Sling 
encircling fetal pelvis: Although it is difficult and often impossible to apply a 
fillet encircling the fetal pelvis, with the ends passing down between the thighs, it 
is the safest and most efficient way. The English advise the use of a soft handker- 
chief for the purpose, but a piece of four-inch gauze bandage a yard long, boiled 
and lubricated with a 1 per cent, lysol solution, answers better. A knot is tied 
at each end, and one knot is carried with the fingers, an English catheter, or a 
porte-fillet, on one groin from without inward, until the knot can be reached be- 
tween the thighs and drawn down. In like manner the other end of the fillet is 
passed over the opposite groin from without inward, thus bringing both ends of 
the fillet down between the thighs. With the whole hand if necessary in the 
vagina, the center of the fillet is adjusted up over the buttocks and around the 
fetal pelvis by an upward movement of the internal hand and downward traction 
on the two ends of the fillet with the external hand. The fillet is thus made to 
make traction on the external circumference of the pelvis, thus relieving the 
groins from the dangerous traction exerted by the other forms of fillet. It is 
not always possible to adjust this sling after the breech is firmly impacted in the 
pelvis, and even at the pelvic inlet it is at first difficult unless it has been 
repeatedly practised on the puppet and pelvis or manikin (Fig. 1186). 

In Version. — It is especially in complicated internal version that the soft fillet 
finds its chief use (page 1004). 

Placenta Praevia. — It occasionally happens that a combined or internal ver- 
sion is performed in placenta praevia; one leg is brought down and the half 
breech used to tampon the partially dilated cervix. Under such circumstances 
the version is not always followed by immediate extraction, and in the mean 
while a soft sling to the prolapsed leg is a convenient way to keep up pressure 
on the placenta and prevent recession of the leg (Fig. 1090). 

Prolapse of the Cord. — In like manner the sling may be used after version in 
prolapse of the cord to hold the half breech temporarily in the partially dilated 
cervix and thus prevent recurrence of the prolapse. 



1080 OBSTETRIC SURGERY. 

In Prolapse of an Arm in Shoulder Presentation (Fig. 1134). — In cases of ver- 
sion in shoulder presentation complicated by prolapse of an arm the sling is ap- 
plied to the wrist and used to draw the arm forward and backward, thus making 
room for the passage of the hand into the uterus, and afterward to prevent 
extension of the arm and subsequent difficulty in extracting the head. In all 
cases care should be taken not to injure a fetal member by tying the sling too 
tightly or making traction too forcibly. Sawing movements should be avoided, 
since they may cause extensive laceration of the fetal parts. When the pre- 
senting part is high and difficult to reach, it is often convenient to pass the loop 
over the operator's arm. It may then be pushed up by a pair of long forceps 
or some similar instrument (Fig. 1137). 




Fig. 1240.— Adjusting a Sling to the Left Anterior Leg. 

Combined Manipulation in Version. — When there is difficulty in turning in 
internal podalic version, in cephalic or shoulder presentation, by reason of the 
grasp of the uterus over the fetus, success may sometimes be obtained by attach- 
ing a sling to a foot and making traction on the foot by means of the end of the 
sling outside of the vagina, and at the same time, with the other hand in the 
vagina, making upward pressure upon the head or shoulder. Skilled assistance, 
by depressing the breech and pushing up the head externally, will greatly aid the 
manceuver (Fig. 11 38). 

Prophylactic Sling in Version. — It has been proposed, as a preliminary to in- 
ternal podalic version, to fasten a sling on one or both fetal wrists in titer 0, the 
object being at all stages of the operation thus to keep both forearms below the 
chin and prevent extension of the arms. The procedure is a dangerous and 



THE BLUNT HOOK. 



1081 



an unnecessary one, for, although theoretically correct, the manipulation of the 
fetal thorax and umbilical cord will in many cases disturb the equilibrium of the 
fetal circulation and cause asphyxia by premature respiration within the uterus. 




IX. THE BLUNT HOOK. 

The blunt hook, made entirely of metal for aseptic reasons, about twelve 
inches long and with a semicircular curve at the end forming a hook the diameter 
of which is two inches, is still a valuable and 
useful instrument in operative obstetrics (Fig. 
1241). 

Uses. — The use of the blunt hook should 
be confined principally, if not entirely, to the 
extraction of the dead fetus. It may be passed 
over the groin in breech presentation for trac- 
tion, then over the brim of the fetal pelvis, and 
hooked into the ribs or over the shoulders or a 
humerus in difficult shoulder extraction. In 
the case of a living fetus the blunt hook should 
be used with the greatest care, if at all; the soft 
fillet or digital traction is usually to be pre- 
ferred. On the living its use is principally con- 
fined to traction on the anterior or posterior 
groin or both in difficult breech extractions. It 
is not desirable to use this instrument on a living 
fetus unless all other methods of extraction fail, 
by reason of the injury to the fetal soft parts and 
to the head of the femur liable to follow its 
use. To avoid injury to the skin of the groin, 
the writer is accustomed to slip a piece of tightly 
fitting rubber tubing over the hook and shank 
of the instrument, sterilizing the whole before 
use. Wrapping the hook and several inches of W 

the shank with a one-inch gauze bandage also -%VmL* 

answers very well in the absence of the rubber m x 

tubing. The blunt hook, thus protected, care- 
fully and judiciously used, becomes a valuable 
instrument in impacted breech cases, but in the 
hands of the careless and inexperienced in its 
use it is capable of much injury to the fetus. 
It is advisable to pass the hook over the anterior 
thigh in breech cases, since this thigh is lowest 
and most readily reached. It is passed up lying 
flat against the thigh, with the hook pointing H 

toward the anterior surface of the fetal ellipse 

until opposite the groin, the hook then being Fig. 1241. — The Blunt Hook. 
passed over the flexure of the thigh, care being 

taken to have the hook descend between the thighs and not catch on one thigh, 
to avoid damage to the femur and the femoral vessels. The proper adjustment is 
secured by digital palpation between the thighs. 



1082 OBSTETRIC SURGERY. 



X. THE CROTCHET. 

The crotchet was an instrument which in the days of craniotomy was used for 
the extraction of the mutilated head after the vault of the skull had been removed 
piecemeal with the craniotomy forceps. It is practically a sharp hook about 
| inch in length with a suitable handle for traction. The instrument is now 
obsolete, but may be found among the collections of instruments in the older 
maternity hospitals, and upon inquiry at the three largest instrument-makers in 
New York I found the instrument was at first unknown, until reference was made 
to an illustrated price-list. Occasionally in the past ten years I have used the 
instrument in extraction of a dead fetus, when fixed in an axilla, between the ribs, 
or any available part of the body. The blunt hook may be used in the same 
way. Originally, for extraction after perforation or craniotomy the hook was 
passed into the interior of the skull and moved about until a firm hold was secured 
upon the bones of the vault or sides of the skull. It was not intended, nor was it 
possible, to fix it in the foramen magnum, as is so often stated in the text-books. 
Quite another instrument, namely, the vertebral hook, having been used for that 
purpose. 



XI. EXTRACTION OF THE FETUS MUTILATED BY 
EMBRYOTOMY. 

Extraction of the fetus after (i) perforation (page 1013) ; (2) cranioclasis (page 
1016); (3) cephalotripsy (pageio2i); (4) decapitation (page 1025); (5) eviscera- 
tion (page 1030); (6) cleidotomy (page 1031); and (7) spondylotomy (page 1033), 
is described under the heads of these operations as above indicated. 



XII. CESAREAN SECTION. 

Definition. — The term Caesarean section is applied to the operation also called, 
in accordance with modern ideas of nomenclature, laparo-hysterotomy, which 
consists in the extraction of the child through an abdominal and a uterine in- 
cision. 

Historical. — The derivation of the term Cesarean is wrapped in some obscuritv, but 
the best evidence seems to connect it with the name Cassar, which in turn seems very likely 
to have its origin in the root of the verb "casdere," to cut. A form of the operation seems 
to have been known early in the history of Rome, and it is recorded that an ancient ruler 
of that city, Numa Pompilius, caused a law to be enacted requiring the operation on recentlv 
dead women far advanced in pregnancy so that mother and child might be interred sepa- 
rately. Certain tribes have likewise made it customary to remove the child even when there 
was no thought of its survival. Mediaeval records of the operation are few and unsatis- 
factory, and of no great interest except historically. A case is recorded from Venetian 
sources in 149 1, and somewhat later a Swiss peasant is said to have done the operation 
upon his own wife, though certainly not before death. Somewhat later, apparentlv, the 
possibility of doing the operation upon the living began to be discussed, and the question 
of how much risk the mother should be subjected to in order to save the child began to 
be argued. The first operation upon the living appears to have been done in 16 10 by 
Trautman, though it is really only since the advent of antisepsis that the operation can 



CESAREAN SECTION. 1083 

be said to have assumed a recognized and important place among obstetrical pro- 
cedures. The consensus of opinion always has been, and still is, that the life of the mother 
is more important than that of the child, and that the former should not be subjected to 
chances the favorable results of which accrue to a great extent to the latter. The field for 
Caesarean section is therefore limited, though under modern conditions, with a proper 
selection of cases, the risks to the mother have been very greatly diminished and the opera- 
tion has, in many instances, come into competition with embryotomy and symphyseotomy. 
The doctrine of the Roman Catholic Church has always been that it is a mortal sin to com- 
pass the death of the child in order to extract it, and among adherents of that faith this 
fact may sometimes have a bearing upon the choice of this operation in preference to 
embryotomy. The operation of embryotomy upon a living child at or near term is the most 
revolting thing which a medical man can be called upon to do, and whenever there is a 
reasonable prospect that the abdomen can be opened and the child thus removed with no 
greater risk to the mother than is incurred by any procedure which involves sacrifice of 
the child, Caesarean section may be undertaken. The earlier writers in the last half of the 
nineteenth century spoke very disparagingly of Caesarean section and looked upon it as a 
last resort in desperate cases, a fact which explains to a great degree their almost uniform 
lack of success. When antisepsis came in, and when cases began to be properly selected, 
the proportion of successes began to rise, until at present it has reached a comparatively 
encouraging figure. The few instances in history in which prominent men are said to have 
been brought into the world by the abdominal route are not authenticated, and in all it is 
uncertain whether the mother was alive or dead at the time of the alleged operation. 

Indications. — The indications for this operation are of two kinds — positive 
and relative; the former of which may be disposed of in a few words. Caesa- 
rean section is positively indicated when the maternal or fetal dystocia is 
so great that it is impossible to remove the fetus even after embryo- 
tomy. The relative indications for the operation are not so clearly marked. 
When it is evident that embryotomy can be done successfully and without 
great risk to the mother, the question in the presence of a dead child is 
easily decided, but if the child is alive the proper course is not so clear. The 
good results which have recently followed Caesarean section have led many 
operators to consider, that a conjugate of 3 inches (7.62 cm.) with the child 
living, and 2.5 inches (6.35 cm.) with the child dead, requires the operation. 
It is to be remembered that in cases in which the difficulty is due to a flat rather 
than a generally contracted pelvis, a shorter conjugate will suffice to effect 
delivery through the natural passages. In 1887 Lusk, of New York, declared 
that embryotomy in a greatly contracted pelvis was as dangerous to the mother 
as Caesarean section, and that since the former operation always sacrifices the 
child, we should not wait too long before resorting to the latter when other means 
of delivery fail. These views have been substantiated by many later observers. 
We should remember that in rachitic dwarfs the indication for Caesarean section 
is practically always present unless labor is induced at a very early date in the 
pregnancy, and if such patients are met with later we must anticipate the neces- 
sity of the operation. As a rule, Caesarean section should be done at term, but it is 
not necessary to wait for labor to begin. A point in favor of the Caesarean opera- 
tion is that by it measures can be taken to prevent future conceptions by tying 
and dividing the Fallopian tubes. While pelvic deformity is the commonest 
condition which requires this mode of delivery, pelvic tumors of almost any kind 
may be the cause of the dystocia. Eclampsia and placenta praevia have some- 
times been put down as conditions which may occasionally demand Caesarean 
section; however, while it is conceivable that it might be advisable to do the 
operation in eclampsia, it is safe to say that placenta praevia will rarely 
demand it. The decision to operate must always depend to some extent 
upon the characteristics of individual cases, and experience alone will enable us 
to draw uniformly just conclusions, but the figures given above — a conjugate of 
3 inches (7.62 cm.) for a living child and 2.5 inches (6.35 cm.) for a dead one — may 
be taken as correct in indicating the operation, barring special and unusual con- 



1084 OBSTETRIC SURGERY. 

ditions. In cases in which the conjugate is over 3 inches (7.62 cm.), but still some- 
what or considerably under normal, judgment is required to avoid extremes and 
decide between the comparative advantages of premature labor and symphyse- 
otomy. We must not wait until the patient is so exhausted from shock, 
hemorrhage, or sepsis from absorption that she has no recuperative powers left. 
When we have concluded to operate, we have still to choose between Caesarean 
section and the so-called Porro modification. Cameron has made about fifty 
patients sterile by dividing the Fallopian tubes between ligatures, and has had no 
bad results after the operation. This procedure must also be considered, since its 
success naturally removes a great future danger, and the theoretical danger of 
subsequent pelvic hematocele has not been encountered. 

Prognosis. — The prognosis in Caesarean section is yearly improving. 
I am unable, however, to give statistics that will cover all the different varie- 
ties of cases. So long as the results of operations performed in well-equipped 
operating rooms, with every convenience at hand, are included in the results 
obtained under unfavorable environment and with faulty assistance, so long 
will the statistics be misleading. We can state, however, that when the en- 
vironment is favorable, when conveniences and competent assistants are at 
hand, when the mother is in good condition and has not been infected by repeated 
examinations and unsuccessful attempts at delivery, and when the fetus is 
still strong and healthy in the uterus, the danger of Caesarean section to the 
mother is almost nil, and we can assure the patient and her family that the 
child will almost certainly survive. 



OPERATION. 

Preparation of the Patient. — The preparation of the patient, emergencies ex- 
cepted, is exactly the same as for any other laparotomy, with the additional pre- 
caution of cleansing the vagina by scrubbing and the use of alcohol and bichloride- 
of-mercury or lysol solution. In an emergency as much as possible should be 
done, and we can at least be sure of sterile hands, instruments, and dress- 
ings. Provision must be made for liberating the fetal head from below in case it 
has become firmly engaged in the pelvis. 

Instruments. — The instruments required are few and simple. Plenty of 
artery clamps should be at hand, and these, in addition to knives, scissors, dis- 
secting forceps, and needles, are all that are required. Silk and catgut ligatures 
must be ready, and a number of good-sized needles already threaded with silk 
for use in closing the uterine incision. It is hardly necessary to add that the 
bladder should be emptied shortly before the operation is begun. 

Position of the Fetus and Placenta.^ — The position of the fetus should 
previously be made out as accurately as possible, so that, among other 
things, the location of the placenta may be surmised. Cameron's experience 
with Caesarean section has been large, and, according to him, the placenta 
is located as follows for the different positions of the vertex: (I) L. O. A., pla- 
centa posteriorly and to the right. (II) R. O. A., placenta posteriorly and to the 
left. (Ill) R. O. P., placenta anteriorly and to the left. (IV) L. O. P., placenta 
anteriorly and to the right. With these facts before us it is often easier to place 
the uterine incision and also to extract the fetus. 

Abdominal Incision. — The usual incision which is found necessary is about five 
or six inches (12.7 to 15.24 cm.) long, beginning just below the umbilicus, though 
sometimes when the abdomen is pendulous it is advisable to begin just above that 



CESAREAN SECTION. 



1085 



landmark. The incision is to be made in the median line and the abdomen is en- 
tered with the usual precautions. After the abdomen is opened there are some 
variations in the technique according to different authorities, but the differences 




• 



/ 



/ 





Fig. 



1242. 



-Control of the Hemorrhage in Cesarean Section by the Hands of an 
Assistant Grasping Each Broad Ligament. 



are in some of the details and do not affect the general plan of the operation. It 
is advisable to be sure that the uterus is not greatly rotated on its long axis, and 
this fact can be ascertained by noting the position of the Fallopian tubes. The 
next step is the opening of the uterus, before which two important matters are to 



1086 OBSTETRIC SURGERY. 

be attended to. These are the protection of the abdominal cavity and measures 
for the control of hemorrhage. 

Protection of the Abdominal Cavity and Control of Hemorrhage. — The abdo- 
minal cavity is protected by the use of properly disposed gauze pads around the 
edges of the widely retracted wound, or by lifting the uterus firmly against the 
edges of the wound, which are at the same time depressed, and raising it from the 
abdomen as soon as it is emptied, for further manipulations. The hemorrhage 
from the uterine incision may be controlled by a strong elastic ligature drawn 
right over the fundus and slipped down as low as possible and tightened, or, 
better, by the hands of an assistant, one grasping each broad ligament and by 
judicious pressure attaining the same result, and at the same time steadying the 
uterus (Fig. 1242). 

Uterine Incision. — The incision into the uterus should be made rapidly down 
to the membranes and should be about six inches (15.24 cm.) long. If the pla- 
centa should be met, it must be separated and pushed aside, or even bored 
through but not cut.* 

Rupture of Membranes and Delivery of Fetus. — As soon as the incision is com- 
pleted the left hand of the operator is introduced and, without rupturing the 
membranes if possible, the head is sought. The time has now come for the rup- 
ture of the membranes and the seizure of the head or feet, after which the de- 
livery should be completed as rapidly as possible. The hand in the uterus should 
not be withdrawn until the complete extraction of the child is assured, since the 
uterus contracts very quickly after the membranes have been opened. Extrac- 
tion should be done very deliberately. The fetal head is sometimes firmly 
grasped by the lower uterine segment, and to liberate it a finger of one hand 
should be hooked into the mouth and the head flexed until the smallest diameters 
are opposed to the superior strait and lower uterine segment. With the other 
hand the operator makes traction upon the feet in the axis of the uterus. If the 
head does not follow, the second hand placed astride the neck makes pressure 
upon the shoulders, and at the same time endeavors to maintain the head in flexion. 
(See Smellie-Veit method/page 1049.) An extreme condition of incarceration 
of the head in the superior strait should, of course, be recognized and corrected 
before the operation. After the child is extracted it is handed to an assistant 
to be wrapped in warm sterilized gauze, while the cord is clamped in two 
places, between which it is divided, a ligature being applied to the stump sub- 
sequently. 

Placental Delivery. — To detach the placenta it should be grasped and squeezed 
like a sponge, whereupon it gradually comes away. Under gentle traction the 
membranes also peel off. In some cases the placenta lies loose in the uterus after 
the fetus is taken out.. Care is necessary at this stage to keep the fluids from en- 
tering the general abdominal cavity. Many operators raise the uterus entirely 
out of the abdominal cavity and hold it in position for suturing by slipping a hot. 
sterilized towel under it. 

Uterine Sutures. — Sutures should be applied in three planes. Those of the 
deepest row should be about one-half inch (1.27 cm.) apart, they should be intro- 

* Laparo-hysterotomy has been performed with a great variety of uterine incisions, 
but as some standard should be recognized, the anterior median longitudinal section, 
extending from the fundus to the contracting ring, should be regarded as the type. The 
uterine wall is completely divided at a single sweep with due regard to the integrity of the 
placenta. In 1891 Howard Kelly advised a cautious opening of the uterus, just sufficient 
to expose the membranes which formed a hernia into the wound. The amnion is broken 
open and the finger, inserted into the buttonhole thus formed, serves as a guide for the- 
cutting instrument which completes the uterine incision. 



CESAREAN SECTION. 



1087 




Peritoneun 



Muscle. — 



1243. — Suture of the Uterine Wall Extending 

TO BUT NOT THROUGH THE DeCIDUA. 



duced into the external aspect of the uterus about one-fifth of an inch (0.53 cm.) 
from the margin of the incision and should emerge at the level of the space be- 
tween the mucous and muscular layers (Fig. 1243). They are then carried across 
the wound to the same stratum of the opposite cut edge and outward through the 
uterine wall. The second plane consists of half -deep sutures, inserted between 
the deep sutures for closer approximation. Finally, the superficial sutures 
of fine silk unite accurately the peritoneal coat of the uterus (Fig. 1244). It 
must be borne in mind, however, that the first or deep layer is capable of some- 
thing more than mere coaptation and constitutes a distinct form of hemostasis. 
If the usual measures for 
checking hemorrhage have 
been inadequate, the deep 
sutures may be inserted 
and tied at once. The 
presence of a slight anemic 
layer about the tightened 
suture shows us that the 
purpose of the latter is 
served ; to go further would 
be to cut off some of 
the necessary blood-supply 
and favor septic infection. 
There is no need of put- 
ting any antiseptic ma- 
terial in the uterine cavity, nor does it need any other drainage than what 
takes place naturally through the os. 

Ligation of the Fallopian Tubes. — With the consent of the patient, the next 
step in our operation is the ligation and division of the Fallopian tubes. 

Return of the Uterus. — Suture of the uterus being complete, the organ is wiped 
dry and replaced in the abdominal cavity. 

Omental Adhesions. — The next step has reference to the prevention of omental 
adhesions. The omentum, which is normally situated in front of the uterus, is 

brought down and carried behind that organ in 
order to avoid the formation of utero-omental 
adhesions. 

Abdominal Sutures. — The abdominal wound is 
closed with three planes of sutures: viz., contin- 
uous catgut suture for the peritoneum, inter- 
rupted silkworm-gut suture for the half-deep layer, 
and buried running suture for the skin. 

Hemorrhage. — The operation of laparo-hyster- 
otomy thus performed is not attended, as a rule, 
by much hemorrhage. If the bleeding is more 
profuse than usual, it may be controlled by tight- 
ening the elastic ligature or by the hands of an assistant grasping the broad 
ligaments and their contained blood-vessels. It is not well to constrict the 
ligature too persistently, or to tie more than one turn, for fear of provoking a 
reactionary hemorrhage when the constriction is withdrawn. It is better to 
control the hemorrhage by the measures customary in natural delivery; viz., 
friction, heat (application of hot cloths in this case), and the hypodermic 
injection of ergot. The latter drug may also be administered as a prophylactic 
at the moment the fetus is removed. In parenchymatous bleeding sponging 




Fig. 1244. — Suture of the 
Peritoneum in Cesarean 
Section. Two Methods. 



1088 OBSTETRIC SURGERY. 

with hot gauze is advisable. The suturing of the uterine incision has naturally 
a hemostatic effect. 

Bladder. Bowels. Nursing. — The bladder should be emptied by catheter, at 
the end of the operation and as often thereafter as necessary. After each evacua- 
tion a thorough vulval douche should be administered (seepage 949). A hypo- 
dermic of morphin is usually indicated during the first post-operative day, but 
at the expiration of twenty-four hours the child should be allowed to nurse and 
the drug should be discontinued. On the third post-operative day the bowels 
should be moved by enema. 

After-treatment. — The abdominal sutures should be removed from the eighth 
to the twelfth day. An examination should be made after cicatrization is complete 
to determine whether or not adhesions have formed with resulting fixation of the 
uterus. As matters of interest and record it is valuable that the operator, after 
empt}ang the uterus, should note the position of the contraction ring and measure 
the true conjugate. The after-treatment is practically the same as after an ex- 
tensive laparotomy for any condition. Morphin must be used sparingly, and a 
good way to give it is in suppository, from a fourth to a half grain at night. The 
first thing to be given by mouth is hot water in teaspoonful doses, begun soon 
after the nausea from the anesthetic has ceased. At the end of four weeks the 
patient may get up, but should usually wear an abdominal supporter for several 
months. It may be necessary during or soon after the operation to administer 
saline infusion into a vein or by hypodermatoclysis, and no hesitation should 
be felt in adopting this plan. 



XIII. VAGINAL CESAREAN SECTION. 

This operation was first devised by Diihrssen, who has been its chief sponsor 
and advocate. Up to the beginning of the present century he had operated in 
this manner at least twenty-two times, but the majority of standard works make 
no allusion to this innovation. Indications : Diihrssen states that he introduced 
this operation because abdominal Csesarean section possessed all the disadvantages 
of laparotomy, including the formation of a ventral scar with resulting liability to 
ventral hernia. Naturally the vaginal operation is contraindicated in certain 
conditions under which the abdominal operation is especially indicated ; such as 
markedly contracted pelvis (true conjugate less than 3.1 inches, or 8 cm.). The 
leading indications for this form of intervention comprise the combination of 
pregnancy with cancer of the cervix, the uterus being extirpated by the vaginal 
route immediately after the extraction of the child; eclampsia; stenosis of the 
cervix; heart disease, etc. Broadly speaking, the operation is indicated when- 
ever delivery is impossible by reason of obstruction from the soft parts of the 
mother. Operation: The technique as described by Diihrssen in his latest 
paper on the subject * is as follows: The posterior vaginal wall is depressed by a 
wide single-bladed speculum, and the cervix is then drawn downward by two 
tenaculum forceps. The anterior vaginal wall is next detached from the cervix 
by a transverse incision made with scissors, and the cervix is split in the median 
line as high up as the internal os. Two other tenaculum forceps grasp the lips of 
the cervical wound. The vaginal wall and cervix are next reunited with catgut 
sutures and the cervical incision is continued upward into the lower segment of 
the uterus. The fetal membranes now prolapse. The speculum having been 
*" Arch. f. Gynakol.," 1900, Bd. lxi, Heft 3. 



PORRO-CMSAREAN SECTION. 1089 

withdrawn while the cervix is still held with tenacula, the operator then performs 
podalic version. It will sometimes be necessary to prolong the uterine incision 
in order to extract the head. The placenta and membranes are to be extracted 
digitally and the uterus is tamponed with iodoform gauze. The wound in the 
uterus should be closed with six catgut sutures, allowing the external portion 
of the cervix to remain ununited for the purpose of preventing undue contraction. 
It is techically permissible to divide the pelvic floor and perineum, should the ex- 
traction of the child be otherwise impossible (see page 979). If Duhrssen's 
operation were to be performed in connection with cancer of the cervix, the tech- 
nique would necessarily undergo certain modifications by reason of the subse- 
quent vaginal hysterectomy. 



XIV. PORRO-C/ESAREAN SECTION. C0ELIO-HYSTERECTOMY. 
SUPRAVAGINAL HYSTERECTOMY. 

This operation offers an alternative to ccelio-hysterotomy, or Caesarean 
section proper, when natural birth is impossible, and when, the child being alive, 
an attempt is to be made to save it. 

Indications. — Unlike Caesarean section in the narrower sense, it is a mutilating 
operation, destroying the mother's capacity for procreation, and hence the in- 
dication for its employment must be clearly defined. Under the name of the 
Porro operation, or Porro-Caesarean section, this operation has long been domi- 
ciled in Italy. Porro's method, however, is essentially a supravaginal amputation 
of the uterus, while ccelio-hysterectomy may be either total or partial. The 
original indication for the Porro amputation was the prevention of sepsis, when 
the uterine cavity gave evidence of infection. More recently a second indication 
has been evolved, based upon moral and economical grounds. Among the des- 
titute and such as are illegitimately pregnant, and especially in the presence of 
tuberculosis, cardiac disease, etc., the necessity for extracting a child by lapa- 
rotomy should entail the prevention of further pregnancy by removal of the 
uterus. Such women, if submitted to a conservative Caesarean section, would in 
the nature of their dispositions and environments become pregnant again. In 
addition to the risk they themselves undergo from repeated pregnancies, these 
women are clearly unfitted for maternity, and merely add a degenerate unit to 
society. 

Operation. — In the operation of ccelio-hysterectomy much depends upon the 
method of treatment of the uterine stump, which may be left within the abdomen 
or submitted to extra-pelvic management. The extra-pelvic plan of treating the 
pedicle is seldom indicated except when haste is of vital importance ; as when the 
condition of the woman is such that the shock of operation must be reduced to a 
minimum. The inexperienced operator should choose the extra-pelvic method 
as being much the simpler of the two. On the other hand, the extra-pelvic 
method exposes the patient to much greater danger from infection and hemor- 
rhage, and also to a protracted convalescence with incidental disturbance of the 
urinary functions. The technique of the operation is as follows: the abdomen 
and uterus having been incised and the child extracted, the patient is placed in 
Trendelenburg's position, and a hysterectomy clamp applied across the lower 
segment of the uterus, after which the uterine and ovarian arteries and the broad 
ligaments are ligated. The uterus is then amputated at the junction of the in- 
ferior and superior segments. If the intra-pelvic method of treating the stump 
69 



1090 OBSTETRIC SURGERY. 

is adopted, the peritoneum is sutured over the stump (closing the latter) with 
continuous silk sutures, the subperitoneal tissue being included. The pelvis is 
then sponged clean, the stump dropped, and the abdomen closed without drain- 
age. 



XV. CESAREAN SECTION ON THE DEAD AND DYING. 

Cesarean section on the dead has fallen into disrepute at various times and in 
different localities for one of three reasons: First, statistics covering a limited 
experience have appeared to demonstrate that but few children were delivered 
alive in this manner, and that these few succumbed to secondary mortality; 
second, cataleptic women have been subjected to laparotomy under these circum- 
stances; third, dead and dying women can be delivered by version or forceps 
without mutilation, and the children thus delivered show a high percentage of 
survivals. Nevertheless the spirit of the old lex regia which ordained that a dead 
woman in advanced pregnancy should be delivered by celiotomy is still in force, 
because it can be carried out with greater rapidity than version and extraction 
and forceps delivery. AYe know that the fetus may survive its dead mother for 
a certain period (see Coffin Birth, page 728), and that prompt intervention may 
save life. Naturally the child thus delivered will be profoundly asphyxiated 
from failure of the maternal circulation, but it may be resuscitated. When the 
mother has succumbed to a severe type of disease, the child is usually profoundly 
affected even before her death. The chances of survival are therefore far more 
unfavorable than in cases of sudden death of healthy mothers, under which 
circumstances children have survived in titer for as long a period as half an hour. 
But even when the mother is dying by inches of some severe general disease, 
the fetus still has a prospect of survival if celiotomy is performed before the 
entire failure of the placental circulation. It is possible also to extract the child 
rapidly per vaginam from its moribund mother. This operation is, of course, a 
most delicate one, and could be put in practice only under certain conditions," 
such as consent of the mother and her relatives in advance and after consulta- 
tion with representative medical colleagues. The patient should be subjected 
to the most valid differential tests of death or the moribund state. In operating 
upon the dead or dying the same general technique obtains as in the ordinary 
conservative operation on the living. One cannot, however, always be par- 
ticular in the choice of an instrument for making the incisions. 



XVI. CELIOTOMY FOR ECTOPIC GESTATION. 

Rupture is seldom encountered after the early months. In late oper- 
ations performed deliberately for the termination of pregnancy, the incision 
should be made with a view of protecting the placenta. After the abdo- 
men is opened it may be possible to incise the sac extraperitoneally. As a 
rule, the peritoneal cavity must be entered. The broad ligaments should be 
ligated when accessible, to control the ovarian artery. - The sac is incised and the 
fetus extracted. The cord should be tied on the fetal side, divided, and allowed 
to bleed. If gestation has occurred within the broad ligaments, the sac and 
placenta may be extirpated en masse, the technique being the same as in the 
•removal of ovarian or parovarian cysts. All the arteries are tied and the attach- 



DELIVERY OF THE PLACENTA AND MEMBRANES. 1091 

ments of the sac are ligated in sections. After thus securing hemostasis the sac 
and placenta may be brought away. In any case when the placenta is supplied 
by blood-vessels which cannot be controlled, as in pelvic or intestinal attachment, 
it must be left undisturbed. It is sometimes possible to protect the peritoneal 
cavity by suturing the sac to the external wound and allowing it to drain, the 
stump of the funis projecting while the sac is packed with gauze. The placenta 
will tend to come away after a week and may be removed piecemeal. If the fetus 
and placenta have no common envelope, the latter must be left behind ; it may be 
isolated by a Mikulicz tamponade. The wound should be left open until all pla- 
cental tissues have come away and the gauze must be changed as decomposition 
advances. If there is an indication to extract the placenta at once, as in case of 
accidental wound or separation, all hemostatic precautions should be taken, and 
after bringing the organ away the operator should use a Mikulicz tamponade. 
(For celiotomy for rupture of the uterus, see page 1097.) 



XVII. DELIVERY OF THE PLACENTA AND MEMBRANES. 

I. Crede's Method. 2. Dublin Method, j. Digital Extraction. 4. Instrumental Extrac- 
tion. 5. Manual Extraction. 6. Digital Curettage. 7 . Instrumental Curettage. 

1. Crede's Method of Placental Expression. — According to Crede's original 
account of his method,* " the simplest and most natural method of artificially 
removing the placenta consists in inciting and invigorating the sluggish activity 
of uterine contraction. A single energetic contraction of the uterus brings the 
entire process to a rapid end. I have succeeded in innumerable cases, and with- 
out exception, in producing an artificial and powerful contraction of the uterus 
in from fifteen to thirty minutes after the birth of the child, and when the uterine 
action was ever so sluggish, by rubbing the fundus and corpus uteri through the 
abdominal wall — gently at first but gradually with the expenditure of more force. 
As soon as the contraction has reached its maximum, I grasp the uterus entire in 
such a way that the fundus lies in my palm while the fingers and thumb make 
gentle pressure upon the body of the organ. I invariably feel the placenta slipping 
from beneath my fingers, as a rule with such violence that it appears at the ex- 
ternal genitals, or at least reaches the lowest part of the vagina. The patient 
experiences no discomfort from this manipulation beyond an increased sensation 
of pain during the uterine contractions, and it becomes unnecessary to introduce 
the hand into the birth canal, which has already become extremely sensitive as a 
result of the expulsion of the child. The uterus remains permanently contracted, 
hemorrhage is therefore less to be feared, and an inversion of the uterus can never 
occur as a result of a regular contraction, although this accident is always possible 
with the usually adopted method of removing the placenta." Shortly before his 
death Crede modified his method by allowing a delay of thirty minutes after ex- 
pulsion of the child before beginning the use of his method. 

In the absence of a positive indication, such as hemorrhage, artificial expul- 
sion of the placenta should not be resorted to until post-partum uterine con 
tractions have failed, after at least half an hour, to cause a spontaneous separa- 
tion of the placenta and membranes. During this time the fundus of the uterus 
should be held in the hand and in atonic conditions gently rubbed, but never in 
the absence of a positive indication vigorously rubbed, to hasten separation of 
the placenta and membranes, nor should traction ever be made upon the cord for 

*"Klinische Vortrage uber Geburtshulfe," 1853, p. 599. 



1092 



OBSTETRIC SURGERY. 



the same purpose. To carry out the method properly the bladder must be empty ; 
the patient is placed in the dorsal position with the knees drawn up to relax the 




Iff 




, 



Fig. 1245. — Crede's Method of Placental Expression. —(The upper figure is from a 
photograph taken at the Emergency Hospital.) 



anterior abdominal wall (Fig. 1245); the fundus of the uterus is grasped with the 
whole hand, four fingers behind and the thumb in front ; during a uterine contrac- 



DELIVERY 'OF THE PLACENTA AND MEMBRANES. 



1093 



tion the fundus is compressed between the fingers and thumb, the fundus being 
at the same time directed as far backward toward the sacrum as circumstances 
will permit. The other free hand should be held in readiness at the vulva to 
prevent a too precipitate delivery of the placenta, as otherwise the membranes 
may be torn and portions retained. 

Should expression at one post-partum uterine contraction fail, we must wait 




Fig. 1246. — Digital Extraction of the Placenta by Traction with Two Fingers 
Introduced into the Cervix, Assisted by Suprapubic Pressure upon the Fundus. 



for the next contraction and repeat the process. In urgent cases both hands 
may be used to grasp the fundus, the eight fingers behind and the two thumbs 
in front. In this case particular care must be taken not to rupture a possible 
salpingitis or diseased ovary. 

As soon as the placenta emerges from the vulval orifice it should be received 
into the hand (Fig. 643). If the membranes do not readily come away, if is best 
to rely upon uterine compression to expel them rather than to twist them into a 



1094 



OBSTETRIC SURGERY. 



pRESSU.Rfr 



cord by turning the placenta over and over gently, and so gradually separating 
them. Should a fragment be left hanging from the cervix or vagina, it may be 
carefully separated. Such bits as may be retained within the uterine cavity are 
best left to be discharged in the lochia if there is no hemorrhage. After the ex- 
pulsion of the placenta and membranes, they must be carefully examined in order 
to see that they are complete (Fig. 645). 

2. Dublin Method. — The so-called Dublin method of extracting the placenta 
is none other than the procedure which goes by Crede's name. It is true that the 
delivery of the placenta by external manipulation — as opposed to traction on the 
cord — was independently originated by the distinguished Strasbourg professor, 

and was popularized throughout the world 
through his personal advocacy ; but it is none 
the less true that this method of extraction 
has been carried out in Dublin, almost from 
time immemorial. Hence a section on the 
so-called " Dublin method " should possess 
chiefly a historical interest. This question of 
priority was first agitated by M'Clintock and 
Barnes in 1876.* 

3. Digital Extraction. — In most instances 
of retention the placenta lies loose in the 
uterine cavity or is only slightly attached to 
the uterus. In such cases, although Crede's 
method of expression fails, something less 
radical than the introduction of the whole 
hand into the uterus is called for to deliver 
the placenta. The author is accustomed to 
resort to what may be termed digital extrac- 
tion in these cases. After proper preparation 
of the external genitals and vagina, the first 
and second fingers of either hand are intro- 
duced into the vagina, and the other hand 
on the fundus prolapses the uterus upon and 
over the two vaginal fingers. The placenta 
is now seized between the fingers, and by 
combined expression and traction the pla- 
centa and membranes are slowly delivered 
(Figs. 1246, 1247). Anesthesia is rarely 
necessary. 

4. Instrumental Extraction. — Removal of 
the placenta and membranes by means of the placental forceps possesses no 
advantages over digital or instrumental curettage, and I have long since aban- 
doned this method. 

5. Manual Extraction. — As a rule, ether or chloroform should be used. The 
patient is placed in the lithotomy position, the external genitals are thoroughly 
cleaned, and the vulva is separated to its widest extent with one hand. The 
other hand in the shape of a cone (Fig. 11 23) is then carefully passed into the 
vagina. The hand separating the vulva is now transferred to the fundus, which 
it firmly grasps (Fig. 1248). Constrictions, if any exist, should be overcome by 
gradual dilatation with the cone-shaped hand. Should the placenta be found 




Fig. 1247. — Digital Extraction 
of a Piece of Retained Mem- 
branes by Two Fingers Intro- 
duced into the Vagina, Assisted 
by Suprapubic Pressure upon 
the Fundus. 



* ' ' The Dublin Method of Effecting the Delivery of the Placenta. 
M.D., etc. Dublin, 1900. 



By He 



Gellett, 



DELIVERY OF THE PLACENTA AND MEMBRANES. 



1095 



free in the uterine cavity, it is simply grasped and removed. If adhesions 
are present, however, the placenta is best separated by peeling it off by 
means of the fingers from above downward (Fig. 1248). In the presence 
of extensive and firm adhesions great care is necessary not to leave too much 
placental tissue behind, and not to use the finger-nails too vigorously and 
thus lacerate the uterine walls too deeply. In firm adhesion, after the bulk of 
the placenta is removed, the placental site must be repeatedly gone over with the 
finger-tips in order to insure the complete removal of all placental tissue. (See 
digital curettage, page 1095.) I n premature cases, and occasionally at term, the 
use of the smooth or even the sharp curette will be found necessary to clear the 
uterus of debris. The author has never found that the placental forceps pos- 
sessed any advantages over the curette. Following the operation the uterine 




Fig. 1248. — Manual Extraction of the Placenta by the Introduction of the Whole 
Hand into the Uterus, Assisted by Suprapubic Pressure upon the Fundus. 



cavity should be freely irrigated with a 1 per cent, solution of creolm or lysol, 
decinormal salt solution, or 1 : 10,000 sublimate solution. Should atony and 
hemorrhage persist after complete emptying of the uterus, the bleeding is treated 
as in ordinary cases of post-partum hemorrhage. 

6. Digital Curettage. — After proper cleansing of the hands, external genitals, 
and vagina, the os, if necessary, is either digitally or instrumentally dilated to 
allow the passage of one or two fingers. The first and second fingers of either 
hand are then passed into the vagina and the free hand upon the abdomen pro- 
lapses the fundus upon and over the vaginal fingers. The tips of the fingers are 
then made to pass over every portion of the endometrium, using them very much 
as we would the blunt curette to remove all placental or membranous tissue. The 
fingers can conveniently be used as a pair of forceps to withdraw loose pieces of 
debris through the os (Figs. 1247, 1064). Anesthesia can often be dispensed with. 



1096 



OBSTETRIC SURGERY. 



7. Instrumental Curettage. — The patient is placed in the lithotomy position 
with the hips drawn well over the edge of the table. Anesthesia is necessary and 
ether is to be preferred, especially if the patient is somewhat exhausted from hem- 
orrhage. The vulva, lower abdomen, and upper thighs are thoroughly scrubbed 
with green soap and water and afterward with sublimate or lysol solution. The 
vagina is then cleansed in the same way. A soft, five-inch jeweler's brush or a 
swab of cotton or gauze upon long dressing forceps should 
be used for the vagina. A perineal depressing speculum |^\ 

is now inserted and the cervix seized with one or two \j 

pairs of volsellum forceps. Much traction should not 
be made, the object being to 
steadv the uterus. The os is then 






Fig. 1249. — Instrumental Curett- 
age of the Puerperal Uterus, 
with a Cautious Up Stroke 
of the Curette, and a Firmer 
Downward One. 



Fig. 1250. — Sharp Puer- 
peral Curette. 



Fig. 1251. — Blunt 
Puerperal Cu- 
rette. 



dilated with a steel dilator of the Goodell type. The uterine cavity is washed 
out with a sublimate solution (1 : 10,000) or a lysol solution, 2 per cent., a digital 
examination followed by another irrigation is made, and the uterus is curetted. 
The size and position of the uterus should be carefully estimated before the 
curette is introduced, and it may be necessary in rare cases to bend the handle 
of the instrument to suit the utero- vaginal axis. The curette should be carried 
carefully to the fundus, since perforations are usuallv caused bv carelessness in 



OPERATIONS FOR THE CORRECTION OF INJURIES. 1097 

this respect. The downward stroke may be moderately firm. The anterior, pos- 
terior, and lateral surfaces should be carefully scraped, especial care being taken 
to clear the cornua of debris, which frequently accumulates in these situations 
(Fig. 1249). The operator may know when he has reached the uterine wall by 
the characteristic grating sensation. 

Choice of Instruments. — Much has been said as to whether the sharp or dull 
curette is to be used. It will often be best to use both, first the dull curette in 
order to remove the loosely attached decidua and placental tissue, and later the 
sharp instrument for the detachment of smaller adherent fragments and the 
thorough cleansing of the uterine walls. During and subsequent to the operation 
the uterine cavity is freely irrigated. It is not necessary to pack the uterus or 
vagina after the operation, unless this procedure is called for by severe hemor- 
rhage or atony (see page 953). 



(D) OPERATIONS FOR THE CORRECTION OF 

INJURIES. 

I. CELIOTOMY IN RUPTURE OF THE UTERUS. 

I regard the prognosis as almost always justifying abdominal section in uterine 
rupture. All are agreed as to the necessity for this intervention in rupture with 
sepsis. When celiotomy is done upon the preceding indication, the peritoneum 
must be protected at all hazards from the septic contents of the uterus. The 
operator is next confronted with the alternative : Shall he save the' uterus or 
extirpate it? The indications for extirpation are: (1) Evidences of infection; 

(2) presence of extensive contusions and extravasations in the uterine wall; 

(3) presence of extensive laceration of the uterine supports, especially the broad 
ligaments. If these conditions are absent, the rent in the uterus should be 
sutured. Suture of the uterus must be done with extreme care, and if the lips of 
the wound are ragged, contused, or necrotic they should be resected. The sutures 
should involve only the serous and muscular coats (see Technique of Cassarean 
Section, page 1084). In cases in which suture appears impracticable the operation 
of ventro-fixation may be performed, the uterus being attached to the abdominal 
wall in such a way as to separate the uterine from the peritoneal cavity. The 
former is drained through the celiotomy incision. The uterine tissue may be so 
friable that suture of any kind is out of the question. Under these circumstances 
the organ should be tamponed within and without or extirpated. A strip of 
gauze is packed in the uterus and its free ends are allowed to project into the va- 
gina. Other strips are used to cover the uterus, the ends projecting through the 
abdominal wound. In some cases an external tamponade is sufficient. The gauze 
should be allowed to remain in situ until the wound is united. Statistics appear 
to show that suture gives the best results when the rupture has followed delivery 
by the natural passages and tamponing after extraction by laparotomy. When 
the uterus cannot be saved, a Porro operation or complete hysterectomy is the 
alternative. The latter has been practised but a few times, and has developed 
no special indications in comparison with the Porro amputation. The former is 
performed in the typical manner, save that the pedicle will be treated according 
to the seat of rupture. Of course, an extraperitoneal pedicle is always to be 
desired, but when the locality of the laceration renders this impossible the stump 
should be fixed to the abdominal wall or buried in the peritoneal cavity. 



1098 



OBSTETRIC SURGERY. 



II. CELIOTOMY FOR SEPSIS OF THE UTERUS. 

See Fever, Part VII. 







r^ 



Fig. 1252. — Repair of a Deep Laceration of the 
Cervix. 



III. REPAIR OF INJURIES TO CERVIX, VAGINA, RECTUM, 
PERINEUM, AND CLITORIS. 

i. Cervical Lacerations. — The varieties of these lacerations have been de- 
scribed on page 649. Some writers have advised the immediate repair of all 

cervical lacerations, but it 
is now pretty generally con- 
ceded that it is neither 
necessary nor safe, since it 
increases the danger of sep- 
sis and has no compensa- 
tory advantages, but rather 
interferes with drainage. 
Ver}^ deep lacerations, how- 
ever, that cause severe 
hemorrhage and favor ex- 
tension of infection to the 
O parametrium should be 

\,^^^ promptly sutured. 

The instruments needed 
are two pairs of volsellum 
forceps, and a needle-holder 
and large curved needles. In rare cases, as in cicatricial fixation of the cervix or 
in the case of a primipara with very small birth canal, a large speculum may be 
required. The patient being in the lithotomy position, the uterus is depressed by 
external pressure over the fundus. The 
anterior and posterior lips are then seized 
by the volsellum forceps, which assists if 
necessary in drawing the cervix down 
(Fig. 1252). The stitches should be about 
half an inch apart. The first should be 
above the angle of the laceration. In some 
cases a single stitch is sufficient. 

2. Vaginal Lacerations. — Lateral and 
anterior tears of the vagina should be 
repaired in accordance with the gen- 
eral principles laid down regarding in- 
juries of the pelvic floor. Vesical and 
rectal fistulae should be promptly repaired 
if the extent of the injury can be defined. 
In cases of sloughing, however, this cannot 

be done, and it will be necessary to wait for the secondary operation, which 
in the interest of the patient should be performed as soon as possible. It is, 
therefore, of the greatest importance to the patient that an exact diagnosis 
should be made. The presence of vaginal fistula may be confirmed by injecting 




Fig. 1253. — Repaired Lacerated Cer- 
vix. Stitches in Place. — (From a 

photograph taken at the Emergency 
Hospital.) 



OPERATIONS FOR THE CORRECTION OF INJURIES. 



1099 



into the bladder warm milk which has been boiled, or some sterilized solution of 
one of the anilin dyes in harmless quantity. Flatus and feces escape into the 
vagina if the rectum has been penetrated ; urine if the fistula communicates with 
the bladder. The immediate operation does not differ from the secondary opera- 
tion except that there is, of course, no denudation. 

3. Pelvic-floor Lacerations. — The term perineal lacerations as usually em- 
ployed is anatomically incorrect, since it is made to include lacerations of the 
posterior vaginal wall, perineum, and rectum. Since, however, lacerations in- 
volving these structures frequently occur together, and since the operations for 
their repair are frequently combined, it is convenient for clinical purposes to con- 
sider them together under 
three degrees. (See Part V, 
page 652). First Degree: 
Superficial perineal or 
perineo -vaginal lacera- 
tions. These consist usu- 
ally of a tear of skin and 
mucous membrane, and 
may be regarded as exten- 
sions of the tear of the 
fourchette which so often 
occurs in first labors (Figs. 
1254, 1255). Second De- 
gree: Vaginal or vagino- 
perineal lacerations which 
extend more deeply but 
do not involve the sphinc- 
ter ani. These may or may 
not involve the skin sur- 
face of the perineum. The 
former is most frequently 
the case in operative de- 
liveries. Very commonly 
the internal laceration 
takes the form of a trans- 
verse tear within the vagi- 
nal orifice with prolonga- 
tions which extend up one 
or both sides of the poste- 
rior column (Fig. 1255). 
This variety of laceration 
may not be suspected un- 
less the vagina is examined at the close of labor (Fig. 1254). Third Degree: 
Vagino-perineo-rectal lacerations in which the sphincter ani is involved. Tears 
of this degree involving the sphincter ani and rectum extend upward for a vari- 
able distance, and, like tears of the second degree, are prone to follow one or 
both sides of the posterior vaginal wall. Very rarely the column is divided in the 
median line. Central perforations of the perineum or pelvic floor may occur. 
(See Part V, page 654.) In central perforations the fold of skin at the perineum 
may be torn away by the shoulder during delivery, the resulting laceration 
looking like one of the second degree. 

Reasons for Immediate Operation. — Superficial tears of the fourchette which 




=^jm 



Fig. 1254. — First Degree or Superficial Perineo- 
vaginal Laceration of the Pelvic Floor. Right 
Vaginal Sulcus only Involved. Stitches for Re- 
pair in Place. Note the numerical order of passing 
the stitches. 



1100 



OBSTETRIC SURGERY. 



usually occur in first labors do not require attention. Larger superficial tears — 
e. g., those which have a base of from \ to £ of an inch — may become infected, or 
in rare cases may lead to the formation of sensitive scar tissue and should be 
sutured. All other tears should be immediately sutured, since otherwise not only 
is the danger of sepsis increased, but the patient may be a life-long invalid as the 
result of injury to the pelvic floor. If the patient's condition is such that the 
operation is deemed unsafe, e. g., after severe hemorrhage, or if the laceration is 
severe, and the operator distrusts his ability and needs skilled assistance, it may 
be postponed for from twelve to twenty-four hours, careful asepsis being main- 
tained in the mean time. 

General Principles. — The operator should use great care as to asepsis, but 

should not employ chemical 
antiseptics. He should clear 
the field of operation from 
blood by irrigating with 
saline solution and sponging 
with sterilized gauze, and 
bring the parts as nearly as 
possible into their normal 
relations by means of ten- 
acula in order to appreciate 
the extent and character of 
the injury. He should aim 
to secure exact approxima- 
tion of denuded surfaces in 
their normal relative posi- 
tions. H e should snip away 
with the scissors necrosed 
tags or bruised bits of tissue, 
and leave no pockets for the 
collection of stagnant secre- 
tions. This is to be avoided 
by not allowing the needle 
to appear in the wound, or, 
when the Emmet suture is 
used, by entering the point 
again in the deepest part of 
the wound. 

Operation. — In the slight- 
er degrees of laceration an- 
esthesia is not usually neces- 
sary, the tissues being benumbed by pressure, and the patient still perhaps parti- 
ally under the influence of an anesthetic. In the severer forms in which careful 
suturing is required, anesthesia will usually be needed, and if such a rupture occurs 
it is best, if an anesthetic has been administered during the expulsion of the head, 
to continue its use until the laceration has been repaired, thus obviating the 
necessity of re-anesthetizing the patient, and lessening the amount of the anes- 
thetic to be administered. (Compare Management of Labor, Part IV.) The 
patient is placed in the lithotomy position with the hips drawn well over the 
edge of the bed or table, and the upper part of the vagina is temporarily packed 
with sterilized gauze to check the flow of blood and enable the operator to 
see what he is doing. The instruments needed are: needle-holder; small and 




Fig. 1255. — First Degree or Superficial Perineo- 
vaginal Laceration of the Pelvic Floor. Both 
Vaginal Sulci Involved. Shows Method of Pass- 
ing the Stitches for Repair. Note the numerical 
order of passing the sutures. 



OPERATIONS FOR THE CORRECTION OF INJURIES. 



1101 



medium-sized curved needles ; a pair of scissors ; a speculum or retractor for the 
anterior vaginal wall (in tears of the third degree it is well to have two retractors, 
one for each side) ; tenacula; suture material. 

A needle-holder is not absolutely necessary unless the laceration extends far 
up into the vagina. Retractors may be improvised from bent spoons. A single 
suture with the ends left long and held by an assistant takes the place of a tena- 
culum, and ordinary sewing-needles or darning-needles sterilized in a flame may 
be used in an emergency. Silk, silkworm-gut, catgut, or silver wire may be used. 
Catgut is preferable for the vagina, since it does not require removal. Silkworm- 
gut is preferred by many 

operators. It can be easily /j> 

rendered aseptic by boil- 
ing for ten or fifteen min- 
utes. It is especially ser- 
viceable when deep su- 
tures embracing a large 
amount of tissue are to be 
passed. 

First Degree. — The op- 
eration is very simple. 
The sutures are passed as 
in Figs. 1254, 1255. The 
labia being separated by 
the fingers of the left hand, 
the wound is closed from 
above downward by inter- 
rupted sutures, the needle 
being introduced close to 
the upper angle of the 
wound near its margin, 
not appearing in the 
wound but emerging at a 
corresponding point on 
the opposite side. Two 
sutures, with perhaps two 
or three additional su- 
tures for the skin-surface, 
will usually be sufficient. 

Second Degree. — The 
anterior vaginal wall is 
drawn up by a retractor 
and the parts are tem- 
porarily restored to their respective positions by tenacula. The vaginal 
lacerations are sutured from above downward (Fig. 1256). If there are two, 
one on each side of the posterior column, they should, of course, both be re- 
paired, but care should be taken that the posterior column, often bruised and 
detached from below upward, is left in its normal position (Fig. 1256). In order 
that the lower portions of the wounded surface may be lifted up and brought into 
contact in the same relative positions which they previously occupied, the Emmet 
suture should be used. In this method of suturing the needle is not passed 
directly across the wound but downward until it appears in the floor of the lacera- 
tion, then re-entered and carried upward again until it appears at a point on the 




Fig. 1256. — Second Degree or Deep Vagino-perineal 
Laceration of the Pelvic Floor, not Including 
the Sphincter Ani. The Laceration in this Case 
Involves the Left Vaginal Sulcus. Stitches for 
Repair in Place. Note the numerical order of pass- 
ing the sutures. 



1102 



OBSTETRIC SURGERY. 



opposite side of the laceration corresponding to that at which it first entered. 
The first suture closes the upper end of the laceration. " The sutures below this 
must then be passed with the two distinct objects in view: of grasping the torn 
muscular tissue on the lateral wall by deep suturing and of exercising a definite 
lift, each suture helping to lift up the pelvic floor." They should be about one- 
half inch apart. A finger in the rectum should guide the needle and care should 
be taken not to pass it into the rectum. After the sulci have been closed in the 
manner above described, the remaining denuded area will be found surprisingly 
small. It may be closed by a single purse-string suture, which should also be made 

to transfix and hold in its 
f> >. x. proper place the end of 

the posterior column. 
The suture enters the skin 
surface of the perineum 
and emerges at a corre- 
sponding point on the 
opposite side. In place 
of this purse-string suture 
two or three interrupted 
sutures may be used. A 
few superficial sutures 
should be inserted wher- 
ever necessary to secure 
accurate coaptation. 

Third Degree. — The 
results of this variety of 
laceration are so deplor- 
able that an immediate 
operation is of special 
importance. If, how- 
ever, the operator dis- 
trusts his own skill or is 
without suitable instru- 
ments and suture mate- 
rial, it is better to delay 
the operation for from 
twelve to twenty-four 
hours until he can obtain 
skilled assistance. The 
patient being in the lith- 
otomy position and the 
field of operation being 
exposed by retractors, one 
on each side, the rectal tear is first closed from above downward by interrupted 
sutures of silk and fine catgut about one-sixth of an inch apart (Fig. 1257). 
These are passed from one-fifth to one-fourth of an inch from the edge of the 
mucous membrane, taking up just enough of the tissues of the recto- vaginal 
septum to secure a good hold. If catgut is used, the sutures are tied in the 
rectum and the ends cut short. If silkworm-gut or other non-absorbable 
material is used, the sutures are tied in the rectum and the ends left long so 
as to hang out of the anus. The ends of the sphincter should be united bv 
two or three extra fine catgut sutures. If the sphincter has been badlvtorn 




Fig. 1257. — Third Degree or Vagino-perineo-rectal 
Laceration of the Pelvic Floor, in which the 
Sphincter Ani is Involved. Shows Method of 
Passing the Sutures. Note the numerical order of 
the stitches, and that 9 transfixes the sphincter muscle 
on both sides. 



OPERATIONS FOR THE CORRECTION OF INJURIES. 



1103 



and the ends have retracted, they should be drawn out with a tenaculum before 
suturing and the extra sutures in the sphincters should be reinforced by one or 
two sutures of silk or silkworm-gut, which should be passed through the exter- 
nal skin at a greater distance from the torn ends of the sphincter and should 
pass above the angle of the tear and emerge at a corresponding position on 
the opposite side. The 
laceration is thus con- 
verted into one of the 
second degree, the treat- 
ment of which has been 
already described (Fig. 
1256). If the vaginal 
laceration extends far up 
into the vagina, its upper 
portion may first be su- 
tured, next the rectal rent 
and sphincter repaired, 
and the operation com- 
pleted as above described 
(Figs. 1257, 1258). In 
the rare cases of central 
perforation of the peri- 
neum already described, 
the anterior portion of the 
perineum should be divid- 
ed, since it is of no ser- 
vice and prevents proper 
inspection of the deeper 
part of the wound. The 
laceration is then treated 
as already described. 

A fter-treatment. — Th e 
knees should be loosely 
bound together (Fig. 936). 
The use of the catheter 
should be avoided if pos- 
sible. Scrupulous cleanli- 
ness of the external geni- 
tals should be secured, 
and after urination and 
defecation the parts 

should be washed with a weak sublimate solution. If the lochia are normal, no 
douches are indicated. The bowels should be kept open after the second or 
third day. If an enema is necessary, it should be intrusted only to an experienced 
nurse. Since the tube has been passed into the sutured laceration, it should be 
pressed against the posterior margin of the anus. If a vaginal douche becomes 
necessary, the same care should be used, the syringe being pressed against the 
anterior vaginal wall. The sutures should be removed about the eighth or tenth 
day. 




Fig. 1258.— The Rectal and Vaginal Sutures of Fig. 
1257 are Tied, the Former in the Rectum, Leav- 
ing ONLY THE TWO PERINEAL OR EXTERNAL SUTURES, 
IO AND II, AND THE SPHINCTER SUTURE 9 TO BE TlED. 



APPENDIX 



HISTORY RECORDS. 

In Private Practice. — I am in the habit of urging upon my students the im- 
portance of starting some method of history-taking in order that they may subse- 
quently profit by a study of their cases. Should the physician not take up 
some methodical system of recording his cases at the outset of his practice, he is 
not likely to do so later. Of course, it is not always pleasant to acknowledge one's 
errors upon paper, but one can learn as much or more from a subsequent study 
of such errors as from successes. I have at various times in the past used the 
ordinary history sheets and history books for this purpose, but experience has 
proved the card system to be more satisfactory, because simple, orderly, and self- 



.!*?E£Teo. c li^" : 




Fig. 1259. — Card Index Case for Obstetrical Histories. 



indexing. The cards I use are of standard size (6 X 6-j-i inches). Such cards are 
elastic and portable and can readily be used at the bedside or operating room, 
for, when doubled, the history of the patient can be easily carried in the pocket 
or card-case. Any of the different methods of indexing the cards may be used. 
For obstetric cases I use three printed cards: The first, pregnancy (Figs. 
1260 and 1 261); the second, labor (Fig. 1262) and puerperium (Fig. 1263); and 
the third, a diagnosis card (Fig. 1264), which is practically a blank and is used 
for complications and where the first two cards prove insufficient to contain 
a given history. My index cards are made for me by the Globe- Wernicke Co., 
380-382 Broadway, New York. 

The observations to be noted under pregnancy (Figs. 1260 and 1261), labor 
(Fig. 1262), and the puerperium (Fig. 1263) have been carefully selected, and are 
the result of many years' experience in obstetric history-taking. Such card- 
history records, of course, need not be limited to obstetrics, for the same case 
with the blank "diagnosis" cards (Fig. 1264) may be applied to general medicine 

and surgery. 

70 1105 



1106 



APPENDIX. 



Method of using the History Cards. — As already stated, there are only three 
printed cards for each case, as labor and the puerperium are contained upon one 



Kn. Date PREGNANCY. Diaqnoaia 


Mr*, (addrent) (Phone) Date c 


f expected labor 


Nrte i««) 






Family hittory _ 


n it.-- VCardiac- Dwairt o/ctildlUMj.'l 




_ . . rFulllrrm. Iflrrruft,,!. Moitki ./I 




^ . .v rClmrartrr. Compti,athnt.-\ 














rfWu. Prnnl.ti,.. Fofttoirt. Cml^\ 








VAGINAL LLmer SrlmM. PmMtlia. fiatum. Euimilid «ri. £«(•«. Oatt-I.J . . 




COVER] 



Fig. 1260. — Pregnancy Index Card; this Side of Card is for a History of the Case 
and the Examination of Pregnancy; this Card also acts with Others Arranged 
Consecutively as an Index of the Dates of Expected Confinements. 

card. For convenience in indexing and selecting, I use three colors — blue for 
pregnancy, salmon for labor and puerperium, and buff for the diagnosis or blank 
card. The pregnancy cards I keep by themselves, in the proximal end of the case, 



URINE. TREATMENT. 



Fig. 1261. — Reverse of Pregnancy Card; upon this Side of the Card are Recorded 
the Results of the Various Urinary Examinations of Pregnancy, as well as 
Treatment or Remarks. 



until finally indexed, and they constitute during this time an index of cases of 
expected confinement. Upon seeing a case of pregnancy in the office or at the 



APPENDIX. 



1107 



patient's home, the pregnancy card is made out and returned to its place in the 
box, and this becomes a record of a case of an expected confinement (Fig. 1259). 



No. Date of birth . 




Action of uterus during physician's hour 

Vaginal examinations, by. whom made, and Ab. 
Temperature Pulse 



COMPLICATIONS 



. [one kqt/f after labor] 



Fig. 1262. — Labor and Puerperium Card; upon this Side of the Card is Recorded 
the History of Labor; Should More Room be Required for History of Com- 
plications or Operations, a Diagnosis Blank Card (Fig. 1264) is Used in Addi- 
tion. 

Upon the receipt of the first specimen of urine, the analysis, with date, is 
recorded upon the back of the card, as well as any subsequent treatment or re- 



mother: PUERPERIUM. CM1LO: 


... 


™»-™» 


H.U. 


."'^rC. 


sss, 


■— ss 


■sr 


"• ; ."sss 


_ 


«. . 




«-•■ 




— 





____ 






1 




1 

















— 










































•- 
























~ 






— 


— 
































m 








— 











- 
























» 


























"<" 


























~^ 














































,... 


























'«" 
























Remarla: 








rsippln. Pmvum Vtfivit Sttrrlion. P.r.rM™."! 
PHYSICAL EXAMINATION ON -OAT OF PUERPERIUM: U"<'. *"*<•>". «*i'tiv*i*u n* mot.Wj. o/wmu. J 




Child. L NurlWf. J .. [MT MTU VT. 



Fig. 1263.— Reverse of Fig. 1262; Record of Puerperium and Examination of the 
Patient at the End of Puerperium and Attendance. 



marks upon the case. Upon being called to a case of labor, one selects the 
proper pregnancy card and a blank labor card to take with him to the case. 



1108 



APPENDIX. 



During or after labor, the labor card is filled in and left at the case for the nurse 
to record the observations of the puerperium of both mother and child, the 
pregnancy card being returned to its place in the case. 

Should the labor or puerperium prove complicated, requiring more space, the 
history is abstracted on the buff diagnosis card, and given a number referring to 
the detailed account of the case, written on the usual bedside history charts, 
which latter history sheets are filed in large letter- file boxes. The buff abstract 
card is then indexed alphabetically with the other cards. 



(address) Consultation with 



Fig. 1264. — Blank Card Ruled; Used as Extra Card in Pregnancy, Labor, or Puer- 
perium, or as Index Card for General Non-obstetric Subjects. 



At the completion of the puerperium, the labor and puerperium card is re- 
turned to the box. At the end of the year, or other convenient time, all cards 
belonging to a given case are fastened together with a brass clip and indexed 
among the alphabetical guides at the distal end of the box (Fig. 1259). 

Institutional and Educational. — I append a serviceable, convenient, and more 
elaborate obstetric history chart for institutional and educational work, which 
was successfully used for several years at the Mothers' and Babies' Hospital, 
New York 



APPENDIX. 



1109 



FINAL DIAGNOSIS- 



CONFINEMENT No._ 



GENERAL HISTORY. 



Name of Applicant,.. 
Address, 



.Nationality,. 



APPLICATION No.. 



DATE,. 



Another Patient, Physician, Charity Institution, 



' Married, ) 

Single \ 

Widow, ) 
Floor, 



.Age, „..Para,.- 

Room, 



O. . , A r-„*.: i anozner raaent, rnysician, ^/tartly J 

ngin of Application, -j^^^, confined, Hospital, Midwife, 



Husband's Occupation, ... 
Unemployed, how long,_ 
Family Medical History, 



No. in Family, _ .....Now Employed,] Ns [ 

.Husband's Wages per Month, $ — ..Rent per Month, $ 



Age, Firit Walked, Kidneys, Syphilis, 



■n , M . , i siee, rirsi watzca, j\.ic 

Personal History, \ J Ulam ciMio< Htc 

Date of Last Menstruation 

History of Previous Pregnancies, Labors, Puerperii, 



Date of Last Menstruation,] Doubtful, J — Date of Quickening, 

( First Day of, ) 



[Slate Length of Each Pregnancy, Causes of Prematurity, Length of Labors at Term, Operations, Weight of Children, Fever and Complii 
First, Second and) _ _ 



History of Children,] ^'Eaborl 

l Headache, \ 

Condition in Present Pregnancy,^ Edema, 

( Constipation, ' 



. txaminer [Sig»]~ 



Height_ 



Weight, 

General Condition,! n&3EW. = 

Breasts, | i^^^' | 



ANTEPARTUM EXAMINATION. 

I. -EXTERNAL. date, 



Nipples, 



Uterine Axis, Amount Liq. Amnii,.. — 

FetUS, (Location of Head,) (Dorsal Plane) (Small Parts,)... 

'Relation Presenting Part to Brim— Above or Partly Through,) - - 

(Presentalj&l,) . (Position,) - 

Measurements, (Symphysis to Ensifon 
(Iliac Crests)- Inches. 



Uterine Elevation, 

- (Site,) (Estimated Weight,).. 

.(Position and Rate of Fetal Heart,) 



(Right External Obliout,)- 



{Iliac Spii 
—Inches. 



ies. (Syniphysis to Fundus, Y 

Inches. (Trochanters,)- 

(Left External Oblique). 

II.-1NTERNAL. 



Bladder, (Obstructed,) 

Inches. (Circumference of Pelvis,)— 

Inches. (External Conjugate). - 






(External 



-(Long, Short, Thick, Flat.Closed, Ope 
Ope 



External Genitals, j /"£ 

Va gi n a, j RMoe'e'te"'Cystocele, \ 

Cervix, (Position and Condition,). 

(Repaired,) _ _ 

Uterus, (High, Low,) 

Pelvis, (Plane of Symphysis.)—... 

(Interischial,) (Flexibility of Coccyx,). 

Summary of Examination : (.&■« „/ Fetus,) 

(Quantity of Liq. Amnii,) (Probable Time of Labor,) 

(Presentation, _ (Position,) 



(Internal os i fr^'j \ - (Part Presenting,) 

Fetus, (Depth in Pelvis.) (Presentation,) (Position).. 



-(Transverse Diameter of Middle Plane.) 



(Diagonal Conjugate,)-.. 



(Coccyx to Subpubic Arch,) 

. Inches. (Estimated True Conjugate) — 

(Size of Pelvis,)- - - — 

1 9 (Probable Character of Labor,) 

(Plural Pregnancy) (Abnormalities,) ~ 



Examiner [Sign]... 



RECORDS. 

DATE 



Time of Call, 



.19. 



HISTORY OF LABOR. 

Time of Arrival, A.P.M 19— 



Length of Gestation, 



-(Position,). 



Fetal Heart, (Rate.) 

Membranes, (intact) — 

Hemorrhage,— Medication 

Vaginal Examinations made by (Hospital staff) 

Time of Termination of First Stage A.P.M, 

Remarks [Causes of Delay, etc] _ 



FIRST STAGE. 

A.P.M. -.19 Presentation, . 

__ (Time.) Cerv 

R"Ptured,| %%£%*' \ (Time).. 



Position, 



(Ami. Dilatation )- 

Bladder,! £SS 



Rectum, . 



...Diet, 



Caput Succedaneum_ 
Number,. 



.19. Duration of First Stage,. 



.Mins. 



1110 



APPENDIX. 






Presentation,. 



SECOND STAGE. 

Position, ._ Fetal Heart, (Time,) 

Membranes, (/«**,) -Ruptured, j ^™ / - } (7¥«.) Bladder,] fj 

Caput Succedaneum, (Moulding,). Rate and Efficiency of Uterine Contractions. 

Position of Patient at Time of Delivery Medication, 



Hemorrhage,. 



Cord Ligature, j™-f 

Actual Presentation, 

Vaginal Examinations Made by (Hospital staff,) 

Time of Termination of Second Stage, A. P.M. 

Management of Perineum, _ _ _ 

Remarks. \ ^T 7 A """ d ' f 



..Cord About Neck, 



Anesthetic, . 



.Occiput Restituted to Left or Right After Delivery — 
Actual Position, 



- (Internes, ) _. Number. 

_ Duration of Second Stage, Hi 



( Source, 

Hemorrhage, ] Amount, 

( Treatment, ' 



THIRD STAGE. 

_Placenta and Membranes, 



Complete. Incomplete, j 
Method of Delivery, I 



Condition, 
Managemen 

Intact, 



Degree of Laeeration, j 
Empty, Full, ) 
Catheter, f 



Uterus : 
Perineum 
Bladder, j 
Condition of Patient, 

Vaginal Examinations Made by (Hospital Staff.) 

Time of Termination of Third Stage, A..P.M 

Patient Visited by (Attending Physicians, Name and Time,).. 

Patient Delivered by 

Temperature, Pulse, Respiration,.. 

Hour After Completion of Loior.) 



—Douche, JffiT/f — 

{Operation— No. Stitches,) - 



Vulvar Dressing, . 

.Temperature, 



_ Abdominal Binder, 

-Pulse, ____Respiration, 



.Number,- 



Duration of Third Stage, . Hrs.. 

..(Hospital Staff, Name and Time,) 



Height of Fundus Above Symphysis, . 

1ARY OF LABOR. 



Inches. (Observed One 



Remarks, (Charaetir of Labor. ,)_ 



Summary of Duration of Labor: 

Third Stage, Hours. 



First Stage,. 

Mins. 



.Mins. Second Stage, Hours,. 



Total Duration of Labc 



-Hours,. 



Mins. 
Mins. 



COMPLICATIONS AND OPERATIONS. 

(PA THOL CICAL EXAMIA'A TIOXS. ) 



CHILD'S HISTORY. 



DATE AND HOUR OF BIRTH. 



Name of Mother,.. 



Sex, 



Para, ...... 



OBSERVATIONS TO BE MADE AT TIME OF BTRTH 
Degree of Maturity, 



r „j;,- „ \ Living, Stillborn, 

Condition, j .,. W W 



Caput Succedaneum, j ^tion, \ - 

Development of Cranial Bones, j si^cf' Fontanels. \ 
Injuries, .._ Defecation, 



(Absent 
Slight, 



Weight,. 



.Lbs. 



Length, (Tota, 



.Micturition, 

Inches. (Vertex Coccyx,)- 



.... Pulse,- 

.Inches. 



CIRCUMFERENCES. 

Shoulders, , Inches. 

Occipito-Mentrl, _ Inches. 

Sub-Occipito Bregmatic, Inches. 

DIAMETERS. 

Bi-parietal, Inches. 

Sub-Occipito Bregmatic,.. _ Inches. 

Occipito-Mental, Inches. 

Placenta, Membranes and Cord in Plural Births, 
Congenital Anomalies, — _ 



PLACENTA. 

Complete or Not, 

Shape, 



Weight, _ 

Size and Form, — 

Anomalies, {#££'f- 



MEMBRANES. 

Complete or Not, _ 

Site of Rupture, 

Peculiarities, 



CORD. 



Length,. _ 

Insertion, 

Peculiarities, _ 



Examiner, 



APPENDIX. 



1111 



Highest Temperature 

on _.-. Day of Puerperium. 



DAILY RECORD OF MOTHER. 



{PUERPERIUM.-) 



..Day. 



i Temperature, A.M.„ P.H.._.. 

2 Pulse, A.M P.M 



5 Ext. Genitals, 

General Condition, (Treatment) 
Signature, 



6 Bowels, 

7 Bladder, 



9 Nipples, . 
io Diet, 



.-.Day. 



1 Temperature, A.M.._ F 

2 Pulse, A-M P.M. 

3 Uterus, jf^LJ 

4 Lochia, ^tt.^} 

5 Ext Genitals, 



_A.P.M 

6 Bowels, 

7 Bladder, 

8 Breasts, j £%£■ 

9 Nipples, 

io Diet, 



General Condition, (Treatment,) 

- Signature,. 



..Day. 



Date, 

1 Temperature, AM... P.M. 

2 Pulse, A.M P.M 

3 Uterus,] ?%$L,\ 

4 Lochia. \%£2£f-\ 

5 Ext. Genitals, 



Day. 



Date„ 



6 Bowels, 

7 Bladder, 

S TWact-c i Condition, 

8 tsreasts, } sterttum. 

9 Nipples, 

ioDiet, 



[ Temperatu 



General Condition, (Treatment.) - 
Signature,.. 



perature, A.M P.M. 

2 Pulse, A.M P.M 

3 Uterus, jg^J 

4 Lochia, jgr^°M- 

5 Ext. Genitals, 

General Condition, (Treatment,) 
Signature,. 



—A.P.M 

6 Bowels, 

7 Bladder, 

$ Breasts, \%™% 

9 Nipples, 

io Diet, 



Day. Date, 

I Temperature, A.M .P.M. 

•2 Pulse, AM P.M—: 

3 Uterus.] g**^ } 

4 Lochia. iS2&.°* r '} _ 

5 Ext. Genitals, 



—A.P.M 

6 Bowels, - 

7 Bladder, - 

8 Breasts, ] 

9 Nipples,, 
io Diet, 



..Day. 



-A. P.M 



1 Temperature, A.M P.M, 

2 Pulse, A.M 

3 Uterus,] g&J 

4 Lochia..) %■%£& 

5 Ext. Genitals,- 



General Condition, (Treatment) 
Signature,. 



General Condition, (Treatment,) 
Signature, 




..Day 



Date,- 



1 Temperature, A.M._. P.M. 

2 Pulse, A.M P.M_ 

3 Uterus.] g**^ | 

4 Lochia. ] %Z^r^' \ 

5 Ext. Genitals, 

General Condition, (Treatment.) 
S ign at u re , 



6 Bowels . 

7 Bladder, 



9 Nipples, . 
io Diet, — 



Day. Date, 

i Temperature, A.M P.M. 

2 Pulse, A.M '. P.M 

SUterus.lf^,,,} 

4 Lochia. \%Z:'^°^\- 

5 fc.xt. Genitals,— 

General Condition, (Treatment,) . 
Signature,.. 



_A.P.M 

6, Bowels, 

7 Bladder, 

8 Breasts, {£^£ 

9 Nipples, 

io Diet. . 



Day. 

1 Temperature, A.M. 

2 Pulse, A.M 



Date.. 

__P.M 

P.M 



..Day. 



Condition, ) 

4 Lochia. ] Q c T r ':l-r 0iOr - 

5 Ext. Genitals, 



6 Bowels, _ 

7 Bladder, _ 

8 Breasts, ] \ 

9 Nipples, .. 
io Diet, 



1 Temperature, A.M. P.M.. 

2 Pulse, AM P.M 

3 Uterus,] SSL,, | 

4 Lochia. \$Z:a%r° J ° r -\~ 

5 Ext. Genitals, 



6 Bowels, 

7 Bladder, 

8 Breasts. {&» 

9 Nipples, 

io Diet, 



General Condition, (Treatment,) 



General Condition, (Treatment,) . 
Signature,- 



..Day. 



Date._. 



1 Temperature, A.M.._ P.M._ 

2 Pulse, AM P.M 



4 Lochia. JgE&.^f — 

5 Ext. Genitals, 



General Condition, (Treatment,) 
Signature, 



_A.P.M 

6 Bowels, 

7 Bladder, 

8 Breasts, • 

9 Nipples, . 
io Diet, 



.Day. Da 

: Temperature, A.M P.] 

2 Pulse, A.M. P.M._ 



ndition, \ 

Quantity. Odor, | 
Ckaraeter,. j 

5 Ext Genitals, : 



Lochia. 



6 Bowels, 

7 Bladder, 

8 Breasts, {SSI" 

9 Nipples, _ 

io Diet, 



General Condition, (Treatment,) . 
- ^—Signature,. 



PHYSICAL EXAMINATION ON 

Position.) Breasts, 



Fund 

Quantity and Character of Lochia. 

Cervix, 

Position, Sensibility and Mobility of Uterus. 

Discharged, 19 on — 

Transferred, 19 

Au topsy, . . 



.Nipples, . 



DAY AFTER LABOR. 

Perineum, _j 



-Day After Labor. Died 



.Day After Labor to_ 



Day After Labor. 
H ospital. 



Prominent Features of Case, 



Signature,. 



1112 



APPENDIX. 



(Sefsis, Effect, ) 



.Day. 



Umbilicus, \ Her, 



C Grauula(ionl, ' 



Cicatrized on.. 



i Septis, 

DAILY RECORD OF CHILD. 

(TEMPERATURE OF INFANT SHALL NOT BE TAKEN EXCEPT FOR SPECIAL INDICATION.) 



-Day. 



—Day. 

i Temperature, A.M.__ P 

2 Pulse.A.M.- P.M. 

3 Umbilicus,] c £f*\ — 

_. , ( Number, \ 

4 Stools, \ Color '\~ 

5 Urine Passed, __ 



Date,_ 



__.A.P.M 

6Skin,||^; )(Wi I 

7 Eyes, (Discharge,) 

8 Nursing, (Dut,y~ 

9 Vomiting, 

io Weight, 



.19-. 



Signature, 



—-.Day. Date,. 

1 Temperature, A.M P.M... 

2 Pulse,A.M P.M.—. 

3 Umbilicus,] C £* off \ 



5 Urine Passed, 

General Condition,] S c % p ; Z°"th, 
- - Signature, 



8 Nursing, (Diet,).- 

9 Vomiting, _ — 
'iq Weight, _ 



-Day. 



1 Temperature, A.M P.M 

2 Pulse.A.M P.M . 

3 Umbilicus, \%?*\ — 

4 Stools, {£-"•'} 

5 Urine Passed, „„ 

General Condition,] c^faS, 

-.. Signature, 



_a.p.m: 

eskin,]!^,} 

7 Eyes, (Discharge,)- 

8 Nursing, (DUt,y~ 

9 Vomiting, 

io Weight, . 



_Day. 



Date,_ 



1 Temperature, A.M P.] 

2 Pulse.A.M.-. -....P.M.. 

3 Umbilicus,] I"'* 



Color, 

5 Urine Passed, 



General Condition,] f^MZh, 
Signature, 



...-A.P.M 

6 Skin,] ££;,,,,_[. 

7 Eyes, (Discharge,) — 

8 Nursing, (Diet,\ — 

9 Vomiting, 

io Weight, 



-...Day. Date, — 

r Temperature, A.M P.M 

2 Pulse, A.M P.M 

3 Umbilicus,] C P Zf° ff \ 

4 Stools, ]££H 

5 Urine Passed, _ 

General Condition, {%*£& 
Signature, . 



-io._.. 



.Day. 



7 Eyes, (Discharge.) 

8 Nursing, (Diet,) 

9 Vomiting, 

io Weight 



Date,. 

1 Temperature, A.M P.M... 

2 Pulse.A.M P.M. 

3 Umbilicus,] c £* \ 



.A.P.M. 



5 Urine Passed, 

General Condition, {£*,££ f 

- Signature, ... 



6 Skin, {^J- 

7 Eyes, (Discharge,)— 

8 Nursing, (Diet,) — 

9 Vomiting, 

io Weight, 



Day. Date.- 

1 Temperature, A.M P.M. ... 

2 Pulse.A.M P.M..- 

3 Umbilicus,] C P Z?,° ff \ 

4 Stools, | £-»/} _ 

5 Urine Passed, 

General Condition,] %*£%, 
- Signature, 



.Day. 



7 Eyes, (Discharge,). 

8 Nursing, (Diet,,— 

9 Vomiting, 

io Weight, 



Date,. 

i Temperature, A.M P.M... 

2 Pulse, A.M P.M_ 



Pus, 

4 Stools, ]~"'[ 

5 Urine Passed, 



Mouth, 

. Signature, 



A.P.M 

7 Eyes, (Discharge,). 

8 Nursing, (Z>.w,>— 

9 Vomiting, 

io Weight, 



Day. 



.A.P.M... 



19.... 



1 Temperature, A.M P.M.. 

2 Pulse. A.M.__-P.M. — . 

3 Umbilicus,] £f'^ 



5 Urine Passed, 

General Condition,] ^ Mouth , \ 
Signature, _ 



eskin,]!^}- -.. 

7 Eyes, (Discharge,) 

8 Nursing, (Did,) _ 

9 Vomiting, — , 

10 Weight, 



Day. Date, 

1 Temperature, A.M P.M.._ 

2 Pulse.A.M P.M._ _ 

3 Umbilicus,] c £«\- - 

4 Stools,]^} 

5 Urine Passed, 

General Condition, {%££% 

- ~- Signature, 



7 Eyes, (Dsscharge,)- 

8 Nursing, (Diet,,— 

9 Vomiting, J. — 
10 \Veight, 



. Day. Date 

1 Temperature, A.M P.M. 

2 Pulse,A.M.-_ P.M 

3 Umbilicus,] Z<*\ 

4 Stools, {££"•} 

5 Urine Passed, 



-...A.P.M 

6Skin,]!^f 

7 Eyes, (Discharge,)- 

8 Nursing, (Diet,). — 

9 Vomiting, 

10 Weight, 



.Day. 



Date, 

1 Temperature, A.M P.M.— 

2 Pulse.A.M P.M 

j Umbilicus,) %Z*\-r- 

4 Stools, {&"' '' 



Signature, .._.. 



5 Urine Passed, 

General Condition,] %*£& \ 

— Signature, ... 



A.P.M. 

6Skin,]|^.f 

7 Eyes, (Discharge,) - 

8 Nursing, (Diet,) — 

9 Vomiting, 

10 Weight, 



Weight, 

Died, (Date,) - 

Discharged, (Date : y 

Transferred to 



PHYSICAL EXAMINATION ON. 

Umbilicus, __ Eyes, . 



>9- 



-Hospital on.. 



Skin,_ 

Day After Labor. 
-Day After Labor 



DAY AFTER LABOR. 

Diet, 



Retained by Mother, — 

Adopted by Whom, 

Remarks, (Artificial Feeding,).— 

Prominent Features of Case, 



.Placed Out, 



Day After Labor. 



Address, . 



.Legally, 



Signature, . 



NDEX 



A. 

Abdomen, changes in, in pregnancy, 129, 
in puerperium, 739; discoloration of, m 
pregnancy, 129; evisceration of, 1030; 
examination of, in pregnancy, 160-168; 
fetal, enlarged, cause of dystocia, 1030; 
formation of, 58; incision of, in Ce- 
sarean section, 1090; pendulous, 738; 
strise of, 129, 738. 

Abdominal, binder in puerperium, 755; 
muscles, action of, in labor, 478, dias- 
tasis of, 769; pregnancy, 404 405, 
pathology of, 408; section (see Lapar- 
otomy); tumors, 315. 

Ablatio placentae, 238. 

Abortion, after-treatment of, 403 ; age of 
patients in, 390; and premature labor, 
induction of, 956-963; and sexual 
intercourse, relation between, 196; 
anemia after, 399; artificial, in pelvic 
deformity, 7.15; cause of pelvic disease, 
41; causes of, in ovum and embryo, 
391, 392; cervical, 395; clinical pheno- 
mena of, 393; complete, 387; concealed, 
387; concealed, diagnosis of, 396; 
criminal, 387, 396; curettage in, 401, 
403; deciduoma malignum after, 399; 
definition of, 385; diagnosis of, 399; 
differential diagnosis of, 396; duration 
of, 394; embryonal, 394; endometritis 
after, 398; ergot in, 404; etiology of, 
391; frequency of, 389; hemorrhage 
after, 397; hemorrhage in, 397; habit, 
393; habitual, 399; in cholera, 287; in 
erysipelas, 379;. in measles, 379; in 
pelvic deformity, 723; in pneumonia, 
379 ; in retroflexed pregnant uterus, 392 ; 
in scarlatina, 379; in typhoid fever, 379; 
incomplete, 387, diagnosis of, 396; indi- 
cations for induction of, 957; induced, 
387; inevitable, 387; malignant disease 
after, 399; maternal causes of, 391; 
membranes, retention of, in, 394; 
missed, 387, 415, diagnosis of, 396; 
month of gestation in, 390; neglected, 
diagnosis of, 396; ovular, 394; ovum 
in, 387; pain in, 394; parity of 
patients in, 390; pathology of, 387; 
paternal causes of, 392; perforation of 
uterine wall after, 398; polypi after, 
399; prophylaxis of, 399; prognosis of, 
397; recurrence of, 399; relative fre- 
quency of, 392; retarded, 395; septic 
infection in, 398; septic sequelae of, 
398; slow, 395; slow or retarded, 



3S7; spontaneous, 3S7; sterility after, 
399; symptoms of, 393-395; tetanus 
following, 398; therapeutic, in pelvic 
deformity, 721; threatened, diagnosis 
of, 395; treatment of early inevitable, 
401; treatment of incomplete and 
septic, 403; treatment of late, 403; 
tubal, pathology of, 406. 

Abscess, mammary, in pregnancy, 324; in 
newly born, 918; of fixation, in puer- 
peral infection, 818; placental, 243; 
puerperal metastatic, 804; retrophar- 
yngeal, in newly born, 910; submam- 
mary, in puerperium, S^^ 

Absorption of fetus, 306. 

Acanthopelvis, 695. 

Acardia, fetal, in twins, 147. 

Accidental hemorrhage, 237-243. 

Accidents in pregnancy, 416, 417. 

Accouchement force, 1034; in eclampsia, 
354-357; in hemorrhage, 242; in pla- 
centa praevia, 236. 

Acephalus, 282. 

Acetabulum, union of parts of, 424, 

Acetonuria, in pregnancy, 363; in puer- 
perium, 363. 

Acid douches in post-partum hemorrhage, 
639, S03. 

Acids in relation to spermatozoa, 28. 

Acne in pregnancy, 380. 

Acute yellow atrophy of liver, cause of 
sudden death in pregnancy, 416. 

Adenoma of umbilicus, 257. 

Adipoceration of fetus, 306. 

Adnexa,' uterine, changes in, in pregnancy, 
91, in puerperium, 733, 743. 

^Equabiliter justo-major pelvis, 684, 685. 

After-birth. (See Placenta.) 

After-coming head, cephalotribe to, 1024; 
cranioclasis in, 1019; extraction of, 
1044-1054, by forceps, 1051, 1074, 1075, 
by Mauriceau method, 1049, by Prague 
method, 1050, by Smellie method, 
1 046-1 049, by Smellie-Veit method, 
1049, by Wigand-Martin method, 1050. 

After-pains, 734; treatment of, 751. 

Agalactia, 826. 

Age, for establishment of menstruation, 21; 
influence of, on primiparity, 725, on 
progeny, ^y ; in rape statistics, 36; in 
relation to pelvis, 439, 440; most 
common for ectopic gestation, 406; of 
patients in interrupted pregnancy, 390; 
parental, in relation to sex-control, 91; 
of fetus, calculation of, 82-89. 

Air embolism, 842 ; in puerperium, S42 ; fresh 



1113 



1114 



INDEX. 



in pregnancy, 193; in uterine sinuses, 
842; in vein, effect of, 930. 

Aitken's operation of double ischio-pubiot- 
omy, 1005. 

Albumin, in fetal urine, 79; in liquor amnii, 
66. 

Albuminuria, effect of, on newly born, 875; 
in eclampsia, 349; in elderly primiparae, 
725; in hydatidiform mole, 210; in hy- 
dramnios, 216; in multiple pregnancy, 
148; in placentitis, 246; in pregnancy, 
120, 361, 362; in puerperium, 736, 773. 

Albumose reaction from febrile urine, 814. 

Alcohol, effect of, on fetus, 293; in acute in- 
fection, 817; in eclampsia, 337, 338; in 
endometritis, 791, 792; in erysipelas of 
newly born, 912; in intrauterine irriga- 
tion, 951; in irrigation of septic uterus, 
792; in pregnancy, 192. 

Alcoholism, effect of, on fetus, 292, on 
newly born, 875; on spermatozoa, 28; 
in pregnancy, 292. 

Alimentary canal, origin of, 61; formation 
of, 56, 57, 58; proctodeal portion of, 
61. 

Alimentary tract, diseases of, in fetus, 295; 
in pregnancy, 364-368. 

Alimentation, in prematurity, 869 ; rectal, 
in pernicious vomiting, 342. 

Alkalies in relation to spermatozoa, 28. 

Allantois, 68; origin of, 61, 6t,, 68; rudi- 
mentary, origin of, 61. 

Allis inhaler, 935, 1063. 

Alopecia in pregnancy, 382. 

Alum in aphthae of newly born, 913. 

Amaurosis, in pregnancy, 119, 377. 

Amazia, 825. 

Amblyopia, in pregnancy, 119. 

Amenorrhcea, conception during, 25, 371. 

American method of symphyseotomy, 10 10. 

Amnion, 6t,, 64, 65; abnormal tenuity of, 
213; adhesions of, 212,223; anomalies of, 
212, 213; caruncles of, 213; cysts of, 213; 
dermoids of, 213; chorion and, relation 
between, 56; description of, 65; dropsy 
of, 214; ectodermic layer of, 61; forma- 
tion of, 57; in twin pregnancy, 146; 
origin of, 61; plastic exudation of, 212, 
213; secretion of, 66-68. 

Amniotic, adhesions, 212, 215, 223; cavity, 
66, false, 66; fluid (see Liquor amnii); 
sac, 66. 

Amniotitis, 212, 213. 

Ampullar pregnancy, 405. 

Amputation, fetal, 214, 301; from am- 
niotitis, 213; of fetal parts to effect 
delivery, 1031. 

Amyl nitrite, in heart disease of preg- 
nancy, 368; in puerperal syncope and 
shock, 840. 

Anasarca, fetal, 301, 875; gelatinous, 298; 
in newly born, 905. 

Anatomical conjugate diameter, measure- 
ment of, 430, 431. 

Anemia, after abortion, 399; from post- 
partum hemorrhage, treatment of, 640; 
in etiology of accidental hemorrhage, 
237; in pregnancy, 120; pernicious, an 
indication for premature delivery, 957; 
pernicious, in pregnancy, 370; puer- 
peral, 774, 834. 

Anesthesia, as an aid in diagnosis, 935; 



examination of pregnancy under, 182; 
in labor, 933; in obstetrics, 993; in 
pelvic-floor operations, 1100; in primip- 
arae, 934; local, in labor, 936; spinal, 
in labor, 936. 
Anesthetics, in labor, 532, 535, 542; in 
heart disease of pregnancy, 368; in em- 
bryotomy, 1013; in precipitate labor, 
625; in threatened rupture of uterus, 

645- 

Aneurism in pregnancy, 369. 

Angioma of placenta, 252. 

Animation, suspended, of newly born, 878. 

Ankylotic pelvis, 683. 

Annular placenta, 219. 

Anorectal tract, imperforations in, 276, 277. 

Anorexia in pregnancy, 365. 

Anteflexion and anteversion of uterus in 
puerperium, 768. 

Anteflexion of pregnant uterus, 307, 308. 

Antenatal, affections, extending into extra- 
uterine life, 873—878; cutaneous dis- 
eases, 297-299; diseases of fetus, 285- 
303; 873-878; pathology, 257, 258. 

Ante-partum hemorrhage, causes of, 418-420. 

Anterior parietal presentation, 571. 

Antero-posterior diameter, 430; of pelvic 
cavity, 433; of pelvic outlet, 434. 

Anteversion, uterine, effect of, on fetus, 303 ; 
of pregnant uterus, 307, 308. 

Anthrax, in pregnancy, 289; of fetus, 289. 

Anthropophagy, 35. 

Anti-eclamptics , 352, 353. 

Antipyretics, in puerperal infection, 817. 

Antipyrin in labor, 935. 

Antisepsis, in ophthalmia neonatorum, goo, 
901; of external genitals during puer- 
perium, 749. 

Antiseptic dressings in erysipelas of newly 
born, 912. 

Antiseptics, chemical, 157; in treatment of 
puerperal infection, 782. 

Antistreptococcus serum, in puerperal infec- 
tion, 817. 

Antitoxin in tetanus of newly born, 913. 

Anuria in prematurity, 868. 

Anus, formation of, 57; laceration of sphinc- 
ter of, 1 102. 

Aorta, fetal, 81. 

Aortae, primitive, 78, 79. 

Aphasia, puerperal, 837 ; in puerperal throm- 
bosis and embolism, 834. 

Aphthas of newly born, 913. 

Apncea neonatorum, 878. 

Apoplexy, cerebral, at birth, 889; diagnosis 
of, from eclampsia, 349; fetal, 878; fetal, 
bowel excretion in, 79; in pregnancy, 
375; of placenta, 242-245, of placenta, 
cause of ante-partum hemorrhage, 420; 
of decidua, 204, 205; placental, 389, 
cause of fetal death, 304. 

Appendicitis and pregnancy, coexistence of, 
141. 

Appendix, removal of, in pregnancy, 417. 

Appetite, in pregnancy, 118; in puerperium, 
736; morbid; in pregnancy, 118. 

Arch, aortic, in fetus, 82; pubic, 433. 

Areola, secondary, in pregnancy, 118; um- 
bilical, in pregnancy, 121. 

Areolar inflammation, in puerperium, 827. 

Arm, delivery of extended, in breech pres- 
entation, 1045; dorsal displacement of, 



IXDEX 



1115 



573; in breech extraction, 1046; paraly- 
sis of, 892 ; prolapse of, in shoulder pres- 
entation, sling in. 10S0; prolapse of, 
572-574; reposition of prolapsed, 975, 
985; treatment of, in breech presenta- 
tion and breech extraction, 574; treat- 
ment of, in cephalic presentation, 574. 

Arsenicism, effect of, on fetus, 293; in 
pregnancy. 293. 

Arterial, infusion of salt solution, 930; ten- 
sion in labor, 481. 

Arteries, curling, 70; hypogastric, fetal, 81, 
82 ; primary thrombosis of pulmonary, in 
puerperium, 842 ; umbilical, of fetus, 81. 

Artery, ovarian, changes of, in pregnancy, 
in; pulmonary, fetal, 81; uterine, 
changes of, in pregnancy, in. 

Articulation. (See Joint.) 

Articulations, anomalies of pelvic, 769; 
pelvic, in puerperium,. 737. 

Artificial feeding, 854-860; table showing 
proper quantity, number of feedings, and 
intervals for, up to nine months, 857. 

Artificial respiration in asphvxia neona- 
torum, 884-888. 

Ascending vena cava, fetal, 81. 

Ascites, abdominal, diagnosis of, from hy- 
dramnios, 217; and pregnane}*, co- 
existence of, 140; diagnosis of, from 
pregnancy, 139; evisceration in fetal, 
1030; of fetus, 295; of newlv born, 

Asepsis, in labor, 515; in puerperium, 749, 
750, 815, 816; in third stage of labor, 
543 ; obstetric, 152 ; of patient, physician 
and accessories in relation to puerpe- 
rium, 815; of vulva, 154. 

Asphvxia, artificial respiration in, 884-S89, 
Byrd's method of, 884-886, Dew's 
modification of Bvrd's method of, 
885, 886, Laborde's' method of, 887, 
888, Prochownik's method of. 887, 
Schultze's method of, 886, 887, 888, 
Sylvester's modified method of, 887,889 ; 
breech-extraction in. 1039; curative 
treatment of, 883-889; definition of, 
878; diagnosis of, S82 ; etiology of, 880, 
881; false, 879; immediate delivery in, 
884; insufflation in, 888; intrauterine, 
889; nascentium, 878; neonatorum, 
878-889; of newly born, primary, 903, 
904; pathology of, 879, 880; prognosis 
of, 882; prophylaxis of, 883; reflex 
stimuli in. 884; removal of foreign sub- 
stances from air-passages in, 884; 
restoration of respiration in, 884-889; 
resume of treatment of, 888, 889; 
shock treatment of, 888; synonyms of, 
878; treatment of, 883-889; umbilical 
infusion in, SSS; varieties of, 879; white, 
881, 882. 

Aspiration pneumonia, S97. 

Aspirator for removing foreign matter from 
posterior pharynx of newly born, 884. 

Assault. (See Rape.) 

Assimilation pelvis, 707. 

Asthma in pregnancy, 374. 

Astringents, in sudamina. S39; in post- 
partum hemorrhages, 63 q. 

Asylum treatment of psychoses of preg- 
nancy, 377. 

Asystole in labor, 727. 



! Atelectasis, of lungs of fetus, 845; of newly 

born. 880, 904, 905. 
Athelia. S25. 
Atheroma of umbilicus, 257; of vessels, in 

fetus, 295. 
Athetosis in prematurity, 867. 
Atmocausis in septic endometritis, 821. 
Atresia, of cervix, 657; in newly born, 276. 

277; of vagina, 219; of vagina and 

vulva, cause of dystocia, 668; of vulva, 

3 2 °- 

Atrophy, caries and necrosis of the pelvis, an- 
omalies due to, 696; infantile, 924; of 
decidua, 205, 206; of placenta, 219. 

Atropin in galactorrhea, 827. 

Attitude of fetus, 470. 

Audit orv paralvses during the puerperium, 

837'. 

Aura in eclampsia, 347. 

Auricles, fetal, 81. 

Auscultation, errors in, 128. 147; in mul- 
tiple pregnancy, 147 ; of funic souffle, 
133. 134; of placental souffle, 127; of 
uterine souffle, 127, 128. 

Auto-infection, 756-758; in pregnane)*, 152. 

Autosites, 282, 283. 

Autointoxication of pregnancy, Bouchard's 
theory of, 325. 

Auto-toxemia, of pregnancy. (See Renal 
insufficiency '.) 

Autotransfusion in post-partum hemor- 
rhage, 640. 

Auvard's cranioclast, 10 16. 

Avulsion of fetal extremities, 616. 

Axis, of parturient canal, 437, 458; of par- 
turient outlet, 437; of pelvic cavity, 
437; of pelvic inlet, 437; of pelvic out- 
let, 437; of uterus, changes in, in preg- 
nancy, 105, 106. 

Axis-traction forceps, 1056, 1057. 1071, 1072. 

Avers, or American method of symphyse- 
otomy, 1 010. 



B. 

Baby scales, 853. 

Baby's basket, 517; outfit, 517. 

Bacillus, coli communis, in puerperal infec- 
tion, 153; diphtheria in puerperal infec- 
tion, 805 ; bacillus coli in puerperal peri- 
metritis, 798; vaginae, of Doderlein, 

1 53- 

Back, fetal, location of, 162, 163. 

Bacteria, effect of labor on genital and 
perigenital, 775-779; in milk, preven- 
tion of, 855; in puerperal septicemia, 
809; migration of vaginal in labor, 
775; migration upward of vaginal, 
775- 779'» mobilization of in the puer- 
perium, 775, 779; pathogenic passage 
of from mother to fetus, 67. 

Bacteriemia, 823, 824; antepartum, 772; 
puerperal, 779; puerperal, pure, 808; 
with toxemia, puerperal, 809, 810. 

Bacteriology, of genital tract, 777-779; of 
puerperal infectious endometritis, 786; 
of puerperal morbidity, 775-779; of 
vagina in pregnane}*, 152, 153. 

Bacterium coli commune in feces of newly 
born, 847; lactis aerogenes in feces of 
newly born, 847. 



1116 



INDEX 



Bag, obstetric, 517-521; of waters, at 
birth, 66, rupture of, 485, "sausage- 
shaped" protrusion of, 955. 

Bags, hydrostatic, of de Ribes, 960. 

Ballantyne's case, of fetal nephritis, 295; of 
fracture of thigh at birth, 895; of 
scleroma neonatorum, 917. 

Balloon of Champetier de Ribes, in pla- 
centa prasvia, 235, 236. 

Ballottement, in pregnancy, 133; abdominal, 
in pregnancy, 129. 
dage in overdistei 

Bandl's ring, 226, 452. 

Barley water in modification of milk, 855, 
856. 

Barnes' bag in delayed labor, 630; cervical 
bags, in placenta prasvia, 235, 236; 
water-bag, 973, 974. 

Bath, ante-partum, 524; continuous, in 
Ritter's disease, 910. 

Bathing, cold, in menopause, 41; in preg- 
nancy, 193; in prematurity, 869; in 
puerperal fever, 817; of newlv born, 
851, 852. 

Battledore placenta, 222, 223. 

Baudelocque's, cephalotribe, 102 1 : diameter, 
in pregnancy, 170, measurement of, 431 ; 
method of correcting faulty presenta^ 
tions, 982; diameter, 16S. 

Bauer's method of calculating composition 
of modified milk, 856. 

Beak-shaped pelvis. 692. 

Bed, preparation of, for labor, 522. 

Bednar's disease, 919. 

Belladonna applications in rigidity of os, 665. 

Belladonna ointment in phlegmasia alba 
dolens, 804. 

Belly, hanging, 307. 

Bichloride of mercury, as antiseptic, 157. 

Bicornate uterus, hernia of, 314; pregnancy 
in, 414. 

Bilateral club-foot, 711. 

Bile-ducts, congenital obliteration of, 875; 
obliteration of fetal, 295. 

Binder, abdominal, in pregnancy, 193, in 
puerperium, 532; mammary, 832, 833. 

Bipolar cephalic version, 990—992; in breech 
presentation, 991, 992; posture of pa- 
tient in, 991. 

Bipolar podalic version, 993-997 ; in cephalic 
presentations, 995-997 ; in shoulder pres- 
entation, 994, 995; leg to be seized in, 

„. 997- 

Birds, membrane formation of, 61. 

Birth canal. (See Parturient canal.) 

Birth, coffin, 728; live, 499; multiple, 610- 
613; paralvsis, 890-893; traumatisms, 
775, 889-897. 

Births, percentage of premature, 866. 

Bis-iliac diameter of pelvis, 431. 

Bis-ischiac diameter, of pelvic outlet, 434; 
of pelvis, 429. 

Bitrochanteric diameter of pelvis, 429 

Bladder and rectum, distended, cause of 
dystocia, 671. 

Bladder, care of, in puerperium, 751, 752; 
changes in, in pregnancy, 117; diagno- 
sis of distended, from pregnancv, 138; 
distended, and pregnancy, coexistence 
of, 141; distention of, in fetus, 296; dis- 
turbances of, in pregnancy, 133, in 
puerperium, 739; exstrophy or extro- 



version of, 273; fetal, distended, evis- 
ceration in, 1030; gangrene of, 669; 
irritation of, in pregnancy, 359; mal- 
formation of, 320; neglect of, in rela- 
tion to sexual functions, 37; origin of, 
61, 68; rupture of, 650. 

Blastoderm, 52. 

Blastopore, amphibian, 53. 

Bleeding in eclampsia, 348. 

Blindness, in puerperal thrombosis and em- 
bolism, 834. 

Blood, changes in, in pregnancy, 120, 195; 
clots, puerperal hemorrhage from re- 
tention of, 761; condition of, in preg- 
nancy, 370; -count in septicemia, 824; 
diseases of, in pregnancy, 370, 371; 
fetal, 79; in puerperium, 737, 806-810, 
834; moles, 387; of newly born, 849; 
origin of, 61; serum, toxicity of, in 
eclampsia, 347 ; -states, composite, in 
septic puerperae, 824; tumor (see Hema- 
toma) ; velocity of fetal circulation of, 

79- 

Blood-pressure, fetal, 79; in pregnancy, 
119. 

Blood-vessels, diseases of, in pregnancy, 
369, 370; of uterus, changes in, in 
pregnancy, 109-111; origin of, 58, 78; 
pelvic, 449, 450. 

Blot's cephalotribe, 1022. 

Blunt hook, 1081. 

Body-axis, formation of, 56; -cavity, forma- 
tion of, 58; delivery of, 540; -wall, 
formation of, 57; -weight, influence of, 
in shape of pelvis, 441; Wolffian, forma- 
tion of, 60. 

Bone, origin of, 58, 61. 

Bone-diseases of fetus, 299. 

Bones, formation of, 57; pelvic, 423. 

Boric acid solution, in aphtha? of newly 
born, 913; in catarrhal conjunctivitis, 
900; in fissured nipples, 826, 828; in 
gonorrheal stomatitis, 902; in hemor- 
rhage from genitals in female infants, 
916; in ophthalmia neonatorum, 859; 
in puerperal cystitis, 793; in thrush of 
newly born, 913; in umbilical sepsis, 
908. 

Bossi's dilator, 972. 

Bottle, feeding, care of, 859, 860. 

Bougie, in delayed labor, 630; for induction 
of premature labor. 959. 

Bouchard's theory of the autointoxication 
of pregnancy, 325 

Bowel excretion of fetus, 79. 

Bowels, care of, in menopause, 41, in preg- 
nancy, 192, in puerperium, 736, 752; 
neglect of, in relation to sexual func- 
tions, 37. 

Brachial palsy, from injury in labor, 891, 
892. 

Bradycardia in puerperium, 734. 

Brain, changes in, in eclampsia, 348; con- 
gestion of, in pregnancy, 375; diseases 
of, in pregnancy, 375; monstrosity of, 
279, 280; origin of, 61; traumatism of, 
at birth, 889, 890. 

Brandy in puerperal infection, 817. 

Braun's, blunt hook, 1025, 1026; colpeu- 
rynter, in placenta prasvia, 235; cranio- 
clast, 1016, 1017; decollator, 1027. 

Braxton-Hicks's method of version in pla- 



IXDEX 



1117 



cent a prasvia, 235, 236; sign in preg- 
nancy, 127, 217. 

Breasts, absence of, 825; and nipples, care 
of, in puerperium, 752; and pelvic 
organs, relations between, 117, 11S; 
anomalies of, 825, 826; areola of, 118; 
areolar inflammation of, during puer- 
perium, 827; caked, 827; care of, in 
nursing, 752, in pregnancy, 194, in 
puerperium, 749, 752; changes in, in 
pregnancy, 117, 118, 129, 130, 194; 
congestion and engorgement of, 827, 
a cause of hyperthermia, 812, 813; 
diseases of, in puerperium, 827-834; in- 
flammation of, 828; of newly born, 851; 
sensations in, in pregnancy, 118; striae 
of, 118; structure of, 744; super- 
numerary, 825. 

Breech, and face, differential diagnosis of, 
in pelvic presentation, 589; arrest of, 
above pelvic inlet, 1039, at inlet, 1039- 
1042, in pelvic cavity, 1 042-1 044; ex- 
traction, 1038-1044, dangers of, 1039, 
by forceps, 1042, by fillet, 1041, by 
blunt hook, 1041, manual method of, 
1040, time limit of, 1044, traction upon, 
and leg brought down, 1040; impaction 
of, in the pelvic cavity, 1042; presen- 
tation, 579-590. (See Pelvic presenta- 
tion.) 

Bregma, 461; brow, and face presentation, 
manual correction of, 980-983; fetal, 
459; presentation, 532-539. 

Breisky's, cephalotribe, 1022; method of bi- 
manual compression of the uterus, 639; 
method of measuring the antero-pos- 
terior diameter of pelvic outlet, 172. 

Breus's forceps, 1056. 

Bright's disease, chronic, effect of, on preg- 
nancy and fetus, 358. 

Broad ligaments, changes in, in pregnancy, 
113, 114; tumor of, and pregnancy, 
coexistence of, 141. 

Bronchitis in pregnancy, 371. 

Brothers' case of intussusception of the 
newly born, 914; diagram showing the 
mortality of the newly born in New 
York, 865. 

Brow, fetal, 459; permanent posterior rota- 
tion of the, in labor, 557, 558; presen- 
tation, 555-560. 

Bruit, placentaire, in pregnancy, 127, 128; 
uterine, in pregnancy, 127, 128. 

Budin's diagram showing the mortality of 
infants in the first year of life, 865. 

Buhl's disease, 917. 

Bulbo-cavernosus muscle, 447, 448. 

Busch's method of internal cephalic version, 

993- 
Byrd's method of artificial respiration, 884- 
886, 888, 889. 



C. 

Cachexia, infantile, 923, 924. 

Caesarean section, 1082-1090; after vagino- 
fixation, 659; in accidental hemorrhage. 
241; in cancer of uterus, 668; in case 
of monsters, 618; in cornual pregnancy. 
415; in eclampsia, 354; in funnel-shaped 
pelves, 680; in kyphosis, 705; in myoma 



of uterus, 661; in Naegele's pelvis, 683; 
in obstruction of vagina, 670, in ovarian 
tumor, 661, 662; in pelvic deformity, 
715, 716, 718, 719, 720, 722, 723, 724; 
in pelvic tumors, 696; in persistent 
mento-posterior positions, 605; in preg- 
nancy after ventrofixation, 657; in 
Robert's pelvis, 684; in shoulder pres- 
entation, 597; in threatened rupture of 
uterus, 645; in tumors causing absolute 
obstruction to delivery, 659; on the 
dead and dying, 1090; vaginal, in 
occlusion of external os, 667. 

Calcareous degeneration, of placenta, 250; 
of umbilical cord, 255. 

Calcification of fetus, 306. 

Calculi, placental, 250; vesical, in preg- 
nancy, 361, cause of dystocia, 672. 

Canal, alimentary, formation of, 56-58; neu- 
renteric, 53; parturient, description of, 

45 -458- 

Canalized fibrin of placenta, 249. 

Cancer, cause of intra-partum hemorrhage, 
730; following coitus interruptus, 40; 
in menopause, 41: in pregnancy, 294; 
indication for prevention of reproduc- 
tion, 39; of cervix, cause of ante- 
partum hemorrhage, 420, vaginal Cae- 
sarean section for, 1088, Caesarean sec- 
tion for, 668; of uterus, cause of dys- 
tocia, 667, 668, treatment of, 668; 
pelvic, 696; prevention of, 41; syn- 
cytial, 206. 

Cancerous cachexia, effect of, on fetus, 294; 
on newly born, 875. 

Cancrum oris of newly born, 909. 

Cannabis indica in puerperal hemorrhage, 
764. 

Capuron, cardinal points of, 431. 

Caput, obstipum, 897; succedaneum, 488, 
504, 505, 895, 896. _ 

Carbolic acid, as an antiseptic, 157; in endo- 
metritis, 790; in phlegmasia alba dolens, 
804; in puerperal ulcers, 782; in vaginal 
and intrauterine injections, 950. 

Carbon dioxide, eliminated by fetus, 79; 
increase of, in blood, cause of labor, 
482. 

Carcinoma. (See Cancer.) 

Cardiac diseases, dystocia due to, 727; effect 
of, on fetus, 294; in pregnancy, 294. 

Caries of teeth, in pregnancy, 364. 

Cartilage, origin of, 58, 61. 

Caruncular formations after labor, 738; 
myrtiform. 73S. 

Cascara sagrada, in constipation of newly 
born, 922; in constipation of preg- 
nancy. 366. 

Casein of milk, 855. 

Castration, indicated in rudimentary uterus, 
318; in osteomalacia, 384. 

Catamenia, 20. 

Catheterization, 955; in labor. 671; in puer- 
perium, 752, 766; in urinary retention 
in pregnancy, 361; of uterus (Krause's 
method), Q58. 

Cavity, amniotic, 66, false, 66; body, forma- 
tion of, 58; pelvic, boundaries of, 432, 
measurements of. 433, obstetric land- 
marks of. 433, planes of, 435, 436; seg- 
mentation, 53. 

Celibacy, advisable in case of pelvic de- 



1118 



INDEX. 



formity, 715; pelvic disorders due to, 

39- 

Celiotomy. (See Laparotomy.) 

Cell, anabolic phase of, 86; chorionic, selec- 
tive power of, 78; decidual, 4S; decidual 
and lutein, analogy between. 49 ; kata- 
bolic phase of, 86, 87; metabolism of, 
86. 

Cells, in liquor amnii, 66 ; in menstrual 
blood, 24; of chorionic villi, 69; uterine, 
changes in, in menstruation, 21. 

Cellular tissue of pelvis, 448. 

Cellulitis, puerperal, 795, 804. 

Centers of ossification as sign of maturitv of 
fetus, 84, 86. 

Cephalalgia. (See Headache.) 

Cephalhematoma, 895-897. 

Cephalometry, 1S6-190; direct abdominal, 
1 86; from length of fetus. 1S6; from 
period of gestation, 186; indications for, 
188 ; internal instrumental, 188 ; manual, 
190. 

Cephalotomy, 1025. 

Cephalotribe, 102 1; and cranioclast com- 
pared, 1022. 

Cephalotripsy, 1021-1025; in after-coming 
head, 1024; in decapitated head, 1024; 
in detached head, 1076; in pelvic de- 
formity, 722; instruments for, 1022; 
operations of, 1023, substitutes for, 
1024. 

Cerebral apoplexy, at birth, 889, 090; di- 
plegia of fetus, 295; disease, in preg- 
nancy, 375; placental, a cause of fetal 
death, 304. 

Cervical abortion, 395. 

Cervix, affections of, cause of ante-partum 
hemorrhage, 418, 420; bimanual dilata- 
tion, indications for, 966, 967; canal of, 
in pregnancy, 94; changes in, in preg- 
nancy, 93, 151; condition of, in men- 
struation, 21; consistency of, in preg- 
nancy, 93; deep incisions of, in eclamp- 
sia, 355; deviation or malposition of, 
cause of dystocia, 665 ; dilatation of, 453 ; 
dilatation of, instrumental, 969-974; 
dilatation of, in labor, 485, in primiparas 
and multiparas, 453; dilatation of, man- 
ual, 963-969; incisions of, 975: in puer- 
perium, 738; inflammation of, in preg- 
nancy, 418; lacerations and contusions 
of, 649; rigidity of, 663; shortening of, 
in pregnancy, 94, 95; softening of, in 
pregnancy, 125. 

Chamberlen's forceps, 1054. 

Champetier de Ribes' bag, 960, 973, 974; in 
delayed labor, 630; in placenta praevia, 
236, 239. 

Chest, great width of fetal, cause of dystocia, 
620. 

Child. (See Newly-born child.) 

Child and mother, temperature of, com- 
pared, 79. 

Child, care of, after birth, 750, 751. 

Children of albuminuric women, below nor- 
mal standard, 362 ; of eclamptic mothers, 
vitality of, 350; of elderly primiparas, 
725; of epileptics, 378; of tuberculous 
mothers, 374; rape upon, 35, 36. 

Chill, in puerperal infection, 821 ; physiolog- 
ical, after labor, 489, 490; post-partum. 
733; in puerperal perimetritis, 799; in 



pyemia, S09; in sapremia, 806; in sep- 
ticemia. So 9. 

Chloasma of pregnancy, 121, 133, 134. 

Chloral, in labor, 935, 936; in tetanus of 
newly born, 913. 

Chlorides in liquor amnii, 66. 

Chlorinated lime, as antiseptic, 158. 

Chlorine water in puerperal infection, 791. 

Chloroform, administration of, 934; and 
ether, choice between, 933-936; in con- 
vulsions of infants, 923; in labor, 532— 
538; in labor, fetal asphyxia from, 292; 
in manual extraction of placenta, 1094; 
transmission of, from mother to fetus, 
67. 

Cholera, in pregnancy, 287; puerperal, 805. 

Chondrodystrophia fetalis, 299. 

Chorda, 56. 

Chorea, following rape, 35 ; in pregnancy, 
378; of fetus, 295. 

Chorio-carcinoma, 206. 

Chorion, 61, 64, 65; and amnion, relation 
between, 66 ; cells, selective power of, 
78; cystic degeneration of villi of, 208; 
cystic diseases of, 20S-211; develop- 
ment of circulation of, 78; diseases of, 
20S-212; dropsy of villi of, 208; ecto- 
dermic layer of, 61; nbromyxomatous 
degeneration of, 211; formation of, 57; 
frondosum, 69; inflammation of, 211, 
212; in twin pregnancy, 146; lasve, 69; 
origin of, 61, 68. 69; primitive, 46; 
selective power of cells of, 78; true, 78. 

Chyluria in pregnancy, 363. 

Circular vein of placenta, 71. 

Circulation, changes in fetal, 846; charac- 
teristic features of fetal, 82; develop- 
ment of chorionic, 78 ; development of 
placental, 78 ; earliest embryonic, 78 ; 
fetal, 79; of newly born, failure of, 905; 
peculiarities of fetal, 81. 

Circulatory system; diseases of, in preg- 
nancy, 368-371. 

Circumva'llate placenta, 224. 

Clavicles, origin of, 84. 

Cleidotomy, 103 1; in dystocia from un- 
usual width of shoulders and chest, 620. 

Climacteric, 26, 41; conception after, 124; 
diseases of, 41. (See Menopause.) 

Climate, change of, in relation to cessation 
of menstruation, 124; in relation to 
degree of menstruation, 24; in rela- 
tion to menstruation, 23; in relation to 
menopause, 26. 

Cliseometry, 185, 186. 

Clitoris, defects in, 320; adhesion of hood 
of, in newly born, 862. 

Cloaca, persistent, 277. 

Clothing, in pregnancy, 193; in threatened 
eclampsia, 351; of newly born, 852; in 
prematurity, 869, 871. 

Coal-gas inhalations, effect of, on fetus, 293. 

Coal-tar derivatives in puerperal infection, 
S17. 

Cocaine, applications of in rigidity of os, 
665; lotion in. galactorrhea, 827. 

Coccygeus muscle, 447. 

Coccygodynia from labor, 673. 

Coccyx, 423. 

Ccelom, 58; extra-embrvonic, 58. 

"Coffin birth," 728. 

Cohen's method of abortion, 961. 



IXDEX. 



1119 



Coitus in pregnancy, 195. 196; interruptus, 
40; reservatus, 40; time of, most favor- 
able for conception. 26, 27. 

Cold, in hemorrhages of newly born. 916; 
in relation to spermatozoa, 2S; treat- 
ment of mastitis, S31, of ophthalmia 
neonatorum, 901, of puerperal endo- 
metritis. 790-792. 81S: of puerperal 
pelvic peritonitis. Soi, of puerperal par- 
ametritis, 796, 799; of puerperal peri- 
metritis, 799; of puerperal salpingitis 
and oophoritis, 793. of puerperal infec- 
tion, 817. 

Colic, of newly born, 919. 

Colon bacillus, in puerperal infection 153. 

Colon, congenital hypertrophy of, 295; irri- 
gation in puerperal infection, 817. 

Colostrum, description of, 743. 

Colporrhexis, 630. 

Coma in eclampsia, 344, 348. 

Compression, danger of forceps. 1057; in 
treatment of cephalhematoma, 897. 

Concealed hemorrhage, 238. 

Conception, 27; after climacteric, 124; avoid- 
ance of, in pelvic deformity, 691; date 
of, 150-152; in amenorrhea, 25, 357; 
means of preventing, 39, 40; rules for 
avoiding, 25, 26; sequelae of preven- 
tion of, 40; time favorable for, 25, 26. 

Condensed milk, components and reaction 
of, 860. 

Confinement, calculation of date of, 150. 

Congestion, of brain, in pregnancy, 375; of 
organs, in pregnancy, 136; passive, of 
placenta, 243; uterine, from coitus in- 
terruptus, 40. 

Conjugate diameter of pelvis, anatomical, 
430; Baudelocque's, 170, 431 ; external, 
431; external in pregnancy. 170. 172, 
173; external and internal, relation 
between, 170; indirect, 431 ; obstetric, 
431; true, 174-178, 414. 

Connective tissue, origin of, 58. 61. 

Constipation, cause of nonseptic puerperal 
fever, 811, 812; in pregnancy, 118, 
366, treatment of, 192, 193, 366; in 
puerperium, 764, 806, S07, Sn; of 
newly born, 921; treatment of. Sn. 

Contracted pelves. (See Pelvic deformity.) 

Contraction, false uterine, 465; intermit- 
tent, in pregnancy, 127; uterine, in 
labor, 479-482, in third stage of labor, 
490. 

Contraction ring, uterine, 451, 452. 

Convulsions, in eclampsia. 344, 347: of the 
newly born, in atelectasis, 905, in colic, 
920, in constipation, 921. in septic in- 
fection, 907, in Winckel's disease, 917. 

Coprostasis, cause of dystocia. 671. 

Cord, spinal, origin of. 61. (See Umbilical 
cord.) 

Cordiform pelvis, 693. 

Cornual pregnancy, 414. 

Corpus luteum, 18, retrograde changes in, 19. 

Corsets, and abdomen, relation between, t,8; 
first use of, in puerperium, 75S; French, 
maternity, 193; in pregnancy, 193; in 
relation to disease, 3S. 

Coryza neonatorum, septic, 908, 909. 

Cotyledons, placental, 71. 

Cough, nervous and spasmodic, in preg- 
nancy, 374. 



Counter-irritation, in puerperal neuritis, 
836; 

Cow's milk and human, compared, 855 ; com- 
position of, 855. 

Coxalgic pelvis, 708. 

Coxitis, 708. 

Cramps in legs, in pregnancy, 117. 

Cranial bones, injuries of, at birth, 893-895 . 

Cranioclasis, 1015-1020; in pelvic deform- 
ity, 722; substitutes for, 1024. 

Craniotabes, 299. 

Craniotomy. 1024: in dead fetus, 999: in 
interlocking of fetal heads, 614; in ky- 
phosis, 705; in obstructed labor due to 
levator ani, 670; in threatened rupture 
of uterus, 646. 

Craniotraction, 10 16. 

Cranium, changes in cavity of, in preg- 
nancy, 122. 

Cravings in pregnancy, 118, 119. 

Creatin in liquor amnii, 66. 

Crede's. method of placental expression, 
543; method with eyes of newly born, 
900; ointment in puerperal infection, 
818: silver in endometritis, 791. 

Creolin, its use in obstetrics, 910, 911. 

Crochet, 1082. 

Cups, dry, in depressions or indentations of 
cranial bones, 853. 

Curettage, 1096, 1097; choice of instru- 
ments for, 1097; digital, 1095: in 
abortion, 401-404: in puerperal in- 
fections, 819; effects of, 791, 792; 
objections to, 819. 

Cutaneous sepsis of newly born, 910. 

Cyanosis, in atelectasis of newly born. 905; 
in failure of circulation in newly born, 
905; in prematurity, S67; in puerperal 
thrombosis and embolism, 834; of newly 
born, 881; in Winckel's disease, 917. 

Cycle, menstrual, 23. 

Cystic degeneration of chorion, 208. 

Cystic tumor of broad ligament, diagnosis 
of, from hydramnios, 217. 

Cystitis, in pregnancy, 360; in puerperium, 
766, 792, 793, septic, treatment of, 793. 

Cystocele. cause of dystocia, 671, 672; in 
pregnancy, 361. 

Cysts, fetal, 301; of umbilical cord, 255; 
ovarian, diagnosis of, from hydramnios, 
217; pelvic, 696; placental, 250; sub- 
lingual, in newly born, 919 ; vaginal, 322 



D. 

Dead, signs of recent delivery in the, 747. 

Deafness in pregnancy, 377. 

Death, apparent, of newly born. 878; from 
prolonged labor in case of cancerous 
uterus. 643 ; maternal, effect of, on fetus, 
304; of fetus. 304—306; sudden, in labor, 
728, in pregnancy, 416, in puerperium, 
839-842. of newly born, 824. 

Debility, congenital, 866, S76. 

Decapitation, 102 5-1030; extraction after, 
1029. 

Decidua, apoplexy of, 204, 205; atrophy of. 
205, 206; changes in, in puerperium, 
742; development of, 48; disappearance 
of, 4q ; disease of, 199-208; fatty de- 
generation of, 50; graviditatis, 46; re- 



1120 



INDEX. 



flexa, 47, 65, in twin pregnancy, 145, 
146; serotina, 46; vera, 46, 48, 65; in 
twin pregnancy, 145; variations in 
thickness of, 49, 50. 

Decollator, 1027. 

Defloration, 31,35; conditions simulating, 35 . 

Deformities, fetal, classifications of, 259; 
fetal, producing dystocia, 616; of 
genital organs, clinical significance of, 
320; of skull and spine, 274, 276; re- 
current, 296; pelvic, diagnosis of, by 
Rontgen pelvimetry, 183. 

Delirium in labor, 727; in puerperal infec- 
tion, 821. 

Delivery, calculating date of, 150, 151, 152, 
748; different signs of, in primiparas and 
multiparse, 748; feigned, 499; forcible, 
1034; immediate, in asphyxia neo- 
natorum, 884; impregnation subse- 
quent to, 747; of placenta and mem- 
branes, 1 09 1- 1 094; operations for, 1033- 
1097; post-mortem, 728-729; prema- 
ture, indication for, 958; signs of recent, 
747; treatment of mother after, 748; 
unconscious, 500, 501. 

Dementia, gestational, 120, 375, 377; in 
puerperium, 837, 838. 

Dental caries in pregnancy, 364. 

Depressions or indentations of cranial bones 
at birth, 893. 

Dermatitis exfoliativa neonatorum, 910. 

Dermatitis herpetiformis of pregnancy, 3S1. 

Dermoid cysts of newly born, 919. 

Dermoids, cause of dystocia, 662; of um- 
bilicus, 257. 

Determination of sex, 86. 

Deutoplasm of ovum, 44. 

Diabetes, an indication for prevention of 
reproduction, 39; effect of maternal, 
on newly born, 294, 875; in pregnancy, 

294, 3 62 > 3 6 3- 
Diagonal conjugate diameter, 431. 
Diagonal oblique diameters of pelvis, 429, 

43 1 - 

Diameters of pelvis, 174, 182, 428, 434. 

Diaphragm, action of, in labor, 478; forma- 
tion of, 58. 

Diarrhea, in newly born, 920, in septic 
infection of the newly born, 907; in 
pregnancy, 118, 366. 

Diastasis, of abdominal muscles, 769; of 
long bones at birth, 895; of pelvic 
joints, cause of dystocia. 673. 

Diet, effect of mother's, on milk, 745; 
improper, a cause of subinvolution, 192 ; 
in diarrhea of newly born, 920, 921; 
in infantile cachexia, 924; in meno- 
pause, 41; in pelvic deformity, 716- 
717; in pregnancy, 192; in puerperium, 
753; in threatened eclampsia, 351; 
necessity for proper, in girlhood, 37; 
Schenck's, in relation to sex-control 
90. 

Digestion, and assimilation of newly born, 
failure of, go 5, 906; in newly born, 848; 
in puerperium, 736. 

Digestive disturbances, cause of dvstocia, 
728. 

Digestive tract, changes in, in preenancy, 

. XI ?- . 
Digitalis in puerperal infection, 817. 



Dilatation, of cervix, in labor, 485, instru- 
mental, 969-973, manual, 963-969, of 
vagina and vulva, 974-975. 

Diphtheria, bacterial toxemia of, 808; in 
newly born, 874; in puerperium, 805, 
813, 823. 

Diplegia, cerebral, in prematurity, 867. 

Discharge, bloody, vaginal, in ectopic gesta- 
tion, 295 ; in hydramnios, 215; in chronic 
deciduitis, 201; in deciduoma malig- 
num, 207; inhydatidiformmole, 210; in 
labor, 485; in placental polypi, 252. 

Diseases, antenatal, 873-878; due to bac- 
teria and fungi, in newly born, 906- 
913; general, in puerperium, S39; inci- 
dent to change of environment in 
newly born, 903-906 ; of unknown 
nature of newly born, 914-919. 

Disinfection, of hands, 156-159; of vulva, 
928. 

Dislocations, fetal, 301, 895. 

Displacements after interrupted pregnancy, 
398. 

Disposition, change of, in pregnancy, 120. 

Diuretics for newly born, 925. 

Double monsters, 281-285; cause of dys- 
tocia, 616-618. 

Double uterus, 273, 316, 414. 

Douche, hot, in first stage of labor, 629; 
in pregnancy, 193; post-partum, 547, 
vaginal, 961; vaginal in endometritis, 
790-792; after repair of pelvic floor, 
1 103 ; vulval, 949. 

D'Outrepont's method of version, 992. 

Dress in relation to disease, 38. 

Dressings for obstetrical operations, 928; 
for umbilical cord, 852. 

Drink in pregnancy, 192. 

Drovsen's weights of embryo and fetus, 86, 
'88, 89. 

Drugs in induction of abortion and pre- 
mature labor, 958. 

Dry labor, 626. 

Duct, of Arantius, 81; right, of Cuvier, 81; 
Mullerian, formation of, 60; Wolffian, 
formation of, 58. 

Ductus arteriosus, 81, S2, closure of, 846; 
Botalli, persistent, 277; venosus, 78, 
81, 82. 

Dwarfism, general. 272. 

Dysmenorrhea, following coitus interruptus, 
40; from natural defects, 25. 

Dysphagia in retropharyngeal abscess of 
newly born, 910. 

Dyspnoea, in accidental hemorrhage, 240; 
in labor in contracted pelvis, 713; in 
pregnancy, 119, 374; in pulmonary 
embolism, 841; in uremia, 345. 

Dystocia, definition of, 551; due to abnor- 
mal conditions in mother, 622-730; due 
to abnormal conditions in fetus, 551- 
622 ; due to affection of fetal trunk, 620; 
due to anencephalus, 620; due to anom- 
alies of membranes, 622; due to avul- 
sion of fetal extremities, 616; due to 
bregma presentation, 532-535; due to 
cardiac and pulmonary disease, 727; 
due to cerebral and spinal disease, 727; 
due to congenital cystic degeneration of 
kidney, 620; due to congenital cystic 
goiter, 620; due to congenital hy- 



INDEX. 



1121 



drocephalus, 619; due to cystic hy- 
groma, 620; due to cystocele, 671; 
due to decapitation of fetus, 616; 
due to deviation or malposition of 
cervix, 665; due to diastasis of pel- 
vic joints, 673; due to digestive dis- 
turbances, 728; due to distended 
bladder and rectum, 671; due to en- 
cephalocele, 620; due to epignathus, 
620; due to excessive flexion of head, 
551; due to excessively long cord, 
614; due to excessive right lateral 
obliquity of uterus, 649; due to faulty 
attitude, 551; due to faulty position, 
597-610; due to faulty presentation, 
579-597; due to fetal malformations, 
deformities, and anomalies, 616-622; 
due to fetal rigor mortis, 622; due to 
forces, 623-630; due to fractures of 
pelvis, 673; due to general fetal condi- 
tions, 610-622; due to general mater- 
nal conditions, 724-730; due to hema- 
toma and oedema, 670; due to hydro- 
encephalocele, 620; due to hydrone- 
phrosis, 620; due to incomplete 
flexion of head, 551; due to inter- 
marriage of races, 715; due to lacera- 
tions and contusions of cervix, vagina, 
rectum, and perineum, 649-656; due to 
levator ani, 670; due to monsters, 616- 
618; due to multiple birth, 610-613; 
due to multiple or compound pres- 
entation, 613, 614; due to new growths 
of pelvis, 695; due to obstructed labor, 
559-722; due to oversize of fetus, 618; 
due to p el vie deformity , 673-722; 
due to persistent hymen, 670; due to 
premature ossification of fetal skull, 
618; due to rectocele, 672; due to 
rigidity and atresia of vagina and 
vulva, 668-670; due to rigidity of in- 
ternal and external os, 663-665; due 
to rigidity of vulva, 670; due to Roe- 
derer's obliquity, 551, 552; due to rup- 
ture of umbilical cord, 615; due to 
rupture of uterus, 641; due to sacro- 
coccygeal tumors, 621; due to short 
cord, 614; due to trismus uteri, 663; 
due to tumors originating in fetal 
urinary apparatus, 620; due to un- 
usual width of shoulders and chest, 
620; due to vaginal and vulval throm- 
bosis, 670; due to vaginal hernia, 726; 
due to vaginismus, 668; due to vagino- 
fixation, 658; due to vesical calculus, 
672; physical phenomena of, 622; for- 
ceps in, 1061; infantile mortality in, 
914; in elderly primiparae, 724; in 
pregnancy and labor after ventrofixa- 
tion and ventrosuspension, 657; mater- 
nal, 622-730; methods of managing, 
721; shock from, 774. 
Dysuria, due to urinary retention, 360; in 
pregnancy, 359. 



Ear, external, formation of, s6; origin of, 

61. 
Ear presentation, 571-574. 
Echinococci, cause of dystocia, 662. 
Eclampsia, accouchement force in, 356, 

71 



1034; albuminuria in, 349; albumin- 
uria absent in, 350; aura in, 347; 
bimanual dilatation in, 968; bleed- 
ing in, 348; blindness in, 348; Cesa- 
rean section in, 1084; cause of sudden 
death in pregnancy, 416; control of 
convulsions in, 352, 353; without con- 
vulsions, 346; curative treatment of, 
352-357; definition of, 346; diagnosis 
of, 349, from apoplexy, 349, from 
epilepsy, 349, from hysteria, 349, from 
meningitis, 349; diet in threatened, 
351; drugs in (see Treatment); effect of, 
on fetus, 294, 349; on fetus and labor, 
348, on newly born, 875; elimination 
of poisons presumed to cause convul- 
sions in, 353, 354; emptying of uterus 
in > 354, 355; etiology of, 347; exciting 
causes of, 347; frequency of, 346, 347; 
and hepatic lesion, 325; in prim- 
iparae, 357, 724, 725; in pregnancy, 
346, 347, in puerperium, 772; internal 
podalic version in, 997; operative 
treatment of, 354-357; pathology of, 
347; podalic version in, 997; predis- 
posing causes of, 347; preventive treat- 
ment of, 350-352; prodromal period 
of, 347, 348; prognosis of, 349; and 
renal lesion, 324; saline solution in- 
jections in, 929-933; stage of coma in, 
348; stage of invasion in, 348; sympto- 
matology of, 347, 348; and acute toxe- 
mia of pregnancy, differences between, 
S33", treatment of, 350-357; treatment 
of comatose condition in, 353; and ure- 
mia, difference between, 345: urine in, 
349; vaginal Cesarean section in, 1088; 
venesection in, 353. 

Ecthyma neonatorum, 711. 

Ectoderm, 52, 54, 57, 60, 61, 63, 65. 

Ectopia testis, 277. 

Ectopic gestation, 408-413 ; age of, 406 ; celio- 
tomy in, 1090 ; changes in tube and uter- 
us in, 409 ; choice of operative method in, 
413 ; clinical history and terminations of, 
409; definition of, 404; differential diag- 
nosis of, 412; duration of, 409; elec- 
tricity in, 413; elytrotomy in, 413; 
etiology of, 406; false labor and time 
of its disappearance in, 410; frequency 
and classification of, 404; greater fre- 
quency of, in multiparae, 406; historical, 
404; laparotomy in, 413; pathology of 
various forms of, 406 ; physical signs of, 
411 ; prognosis of, 412 ; relative frequency 
of rupture of fetal cyst in, 409 ; retention 
of dead fetus in, 410; signs and progno- 
sis of rupture of, 409 ; symptoms of, 410 ; 
time for intervention in, 413; treatment 
of, 412, 413; various forms of, 406. 

Eczema, in pregnancy, 380; of nipples, in 
pregnancy, 324, in puerperium, 827. 

Edgar's, irrigating tube, 952; method of en- 
gaging fetal head, 188. 

Education in relation to sexual functions, 37. 

Egg, mammalian, 44; nucleus, 44. 

Ehrenfest's geometrical method of depicting 
pelvic cavity, 184. 

Elbow and knee presentation, differential 
diagnosis of, 589. 

Electricity, in galactorrhea, 827; in induc- 
tion of abortion, 962; in paralysis of 



1122 



INDEX. 



arm, 893; in paralysis, traumatic, 837; 
in subinvolution, 768. 

Elephantiasis, congenital cystic, 875; general 
cystic, 298; simple congenital, 875. 

Elliott's forceps, 1056. 

Ellipse, fetal, 471; measurement of, 151; 
shape of, 494. 

Elytrotomy in ectopic gestation, 413. 

Emanuel's disease, 246. 

Embolism, air, in puerperium, 805; puer- 
peral, 834; pulmonary, cause of sud- 
den death in puerperium, 841. 

Embryo, anatomy of, 52-65; arrested de- 
velopment of, 258; characteristics of, in 
different lunar months, 82; destruction 
of, by hemorrhages into decidua, 202; 
destruction of, 257; earliest circulation 
of, 78; Eternod's, dimensions of, 83, first 
month, 82, fourth week, 8^; in different 
months of gestation, 86, 88, 89 ; nutrition 
of , 7 7 , 7 8 ; pathology of early human, 257; 
Peters', 47, 65, second month, 84; Spee's, 
65, dimensions of, 83; vitelline circula- 
tion of, 78. 

Embryology, suggestions for study of, 43. 

Embryonal abortion, 394. 

Embryotomy, 1010-1012; in cancer of uter- 
us, 668; in face presentation, 570; in 
over-developed fetus, 618; in pelvic de- 
formity, 718, 719, 720, 722, 724; in per- 
sistent mento- posterior positions, 605; 
in threatened rupture of uterus, 646; 
lowest limit for, 1083. 

Emotion, in etiology of accidental hemor- 
rhage, 239; the cause of fever in puer- 
perium, 814; in relation to menstrua- 
tion, 24, 25, 124. 

Emphysema in pregnancy, 371. 

Enamel, origin of, 61. 

Encephalocele, 275, 280, 897; cause of 
dystocia, 620. 

Enchondromata, pelvic, 696. 

Endarteritis, of umbilical cord, 256. 

Endocarditis, acute, in pregnancy, 368; 
chronic, in pregnancy, 368; of fetus, 294, 
875; puerperal, 806. 

Endometritis, after abortion, 398; cause of 
interrupted pregnancy, 392; cervical, 
cause of ante-partum hemorrhage, 418; 
chronic, cause of fetal death, 303; de- 
cidual catarrhalis, 201; decidua? diffusa 
chronica, 203; deciduae cystica, 204; fol- 
lowing coitus interruptus, 40; due to 
mixed infection, in puerperium, 787— 
792 ; gravidarum catarrhalis, 201 ; gravi- 
darum hyperplastica, 202 ; in etiology of 
accidental hemorrhage, 240; puerperal, 
782-792 ; puerperal, composite, 787-792 ; 
puerperal, infectious, 785-787; puer- 
peral, malignant, 787, 794, 795; puer- 
peral, results of, 773; puerperal, sapro- 
phytic, 783-785; puerperal, simple 
putrid, 782-785; puerperal, simple pyo- 
genic, 785-787; puerperal, ulcerative, 
809; puerperal, variety of, 782, 783; 
puerperal, treatment of, 790-792. 

Endometrium, changes in, in menstruation, 
21. 

Endophlebitis of umbilical cord, 256. 

Endotrachelitis, diagnosis of, from hy- 
drorrhcea gravidarum, 201; in preg- 
nancy, 128. 



Enema, after repair of pelvic floor, 1103; 
ante-partum, 524 ; in colic of newly born, 
920; in constipation of newly born, 
922; in constipation of pregnancy, 366; 
in convulsions of newly born, 923; in 
post-partum hemorrhage, 641; in puer- 
peral constipation, 811. 

Engagement of head in vertex presentation, 
492, 506, 509. 

Enteralgia of pregnancy, 366. 

Enteroclysis, 931. 
I Enteron, formation of glands of, 57; primi- 
tive, 53. 

Entero-teratomata of umbilicus, 256. 
J Entoderm, 53, 54, 57, 61, 63, 65. 

Epidemic hemoglobinuria of newly born, 

^ . 9I7.. 9i8- 

Epidermis, 54; amnion continuous with the, 
65, 66; origin of, 61. 
J Epilepsy, diagnosis of, from eclampsia, 349; 
due to cerebral hemorrhage in labor, 
890; following rape, 35; indications 
for prevention of reproduction in, 39; 
in pregnancy, 378. 

Epileptic mother, offspring of, 875. 

Episiotomy, 978; in dystocia due to 
oedema, 671. 

Epispadias, 273. 

Epithelium, glandular, origin of, 61. 

Ergot, after abortion, 403 ; after labor, 
547; cause of rupture of uterus, 643; 
in accidental hemorrhage, 242 ; in hemor- 
rhages of newly born, 916; in hydram- 
nios, after labor, 219; in puerperal 
endometritis, 790, 792; in puerperal 
hemorrhage, 764; in puerperal sep.tic 
phlebitis, 803 ; in puerperal infection, 
817; in puerperium, 757; in subinvolu- 
tion, 768. 

Ergotin, in galactorrhea, 827; in puerperal 
neuritis, 836. 

Erosions, cervical, cause of ante-partum 
hemorrhage, 418. 

Eructations in pregnancy, 118. 

Eruptions in septic infection, in puerperium, 
839. 

Erysipelas of fetus, 286; of newly born, 
912; in pregnancy, 286, 379; in puer- 
perium, 805 

Erythema, puerperal septic, 808. 

Erythrocytes, disintegration of, in Winck- 
el's disease, 918. 

Ether, administration of, 934; and chloro- 
form, choice between, in labor, 933, 
936, in obstetric operations, 935, 936, 
in first stage of labor, 629; in labor, 
53 2 > 535; m labor, fetal asphyxia 
from, 292; in manual extraction of 
placenta, 1094; poisoning in fetus, 291, 
292. 

Eustachian tube, origin of, 61. 

Eustachian valve, 82; fetal, 81. 

Evisceration, 1030. 

Evolution, spontaneous, in shoulder pres- 
_ entation, 593. 
J Ewings' theory of toxemia of pregnancy, 
326. 

Examination, methods of, in diagnosis of 
pregnancy, 127; in obstetrics, limita- 
tion of internal, 816. 

Excitement, emotional, cause of fever in 
puerperium. 814; in relation to men- 



INDEX. 



1123 



struation, 24; to be avoided in preg- 
nancy, 194, 195. 

Excretion, bowel, of fetus, 79; kidney, of 
fetus, 79. 

Exenteration or evisceration, 1030. 

Exercise, for newly born, 861; in preg- 
nancy, 191, 192; in puerperium, 757; 
in threatened eclampsia, 351. 

Exophthalmic goitre in pregnancy, 371. 

Exostoses, fetal, 301. 

Expression of fetus, 1033; in pelvic presen- 
tation, 590. 

Expulsion of head in normal labor, 506, 
509, 512; of trunk in normal labor, 
508, 509. 

Extension of fetal head, 462; of head in 
normal labor, 507, 509. 

External and internal method, combined, 
of correction of bregma, brow, and 
face presentation, 981. 

External, cephalic version, 948; method of 
correction of bregma, brow, and face 
presentations, 980; oblique diameters 
of pelvis. 429; podalic version, 993. 

Extraction after decapitation, 1029. 

Extrauterine and intrauterine pregnancy, 
coexistence of, 405. 

Extrauterine pregnancy, ruptured, diag- 
nosis of, from accidental hemorrhage, 
241. (See Ectopic gestation.) 

Extremities, changes in lower, in preg- 
nancy, 117. 

Exudations, pelvic, diagnosis of, from preg- 
nancy, 139. 

Eyes, formation of, 55; of newly born child, 
cleansing of, 538; loss of, from purulent 
ophthalmia, 899. 

F. 

Fabre's method of measuring superior 
strait, 184. 

Face, deformities of, 271; mistaken for 
breech, 589; monstrosity, 279, 280; trac- 
tion on, in breech cases, 1 046-1 049. 

Face presentation, 560-571; and breech pres- 
entation, differential diagnosis of, 589; 
conversion of, into vertex, 570; em- 
bryotomy in, 570; forceps in, 570, 1076; 
internal podalic version in, 997; man- 
ual correction of, 980-983; mechan- 
ism of, 562, 563; method of internal 
recognition of, 568; perforation in, 
10 15; podalic version in, 993; prolapse 
of cord in, 685; treatment at pelvic 
inlet, 570; treatment of , in pelvic cavity, 

57°- 

Facial bones, fracture of, at birth, 893. 

Facial paralysis, spontaneous, 890, trau- 
matic, 890, 891. 

Fallopian tubes, ciliary current in, 18; 
ligation of, in Caesarean section, 1087; 
obliteration of, for prevention of con- 
ception, 40; origin of, 60; pregnancy 
in. 405. 

Faradism in puerperal hemorrhage, 764. 

Fat, abdominal, diagnosis of, from preg- 
nancy, 138. 

Fatigue, extreme, from dystocia, 774. 

Fats, regulation of, in modified milk, 855, 
856. 

Fatty degeneration of newly born, 917; 



of heart in pregnancy, 369; of placenta, 
251. 

Fecal accumulations, cause of dystocia, 671; 
diagnosis of, from pregnancy, 138. 

Feces, of newly born, 817. 

Fecundation, 27. 

Feeding, artificial, 854-859; infant, proper in- 
tervals for, 853; in post-partum hemor- 
rhage, 641. 

Feet, extraction by, in breech presentation, 
1042-1044. 

Feigned delivery, 499. 

Female pronucletis, 44. 

Fertilization, 27, 44; in relation to sex- 
control, 91. 

Feticide, 40, 387; therapeutic, 40, 41. 

Fetus, 458; abnormalities of, 259-285; 
absorption of, 306; acute poisoning of, 
292; adipoceration of, 306, in missed 
labor, 416; amputations of, 301; ante- 
natal diseases of, 285-304; anthrax of, 
289; aorta of , 81; ascites of , 295; atelec- 
tasis of lungs of, 845 ; atheroma of vessels 
of, 295; attitude of, 470; auricles of, 81; 
axis of ellipse of, in different weeks, 
151; biparietal diameter of, in different 
months, 88, 89; bladder distention of, 
296; blood of, 79; blood-pressure in, 
79; blood velocity in, 79; bone disease 
of, 299; bones of head of, 460; bowel 
excretion of, 79; brain vesicles of, 
formation of, 84; calcification of, 306, 
in ectopic pregnancy, 410, in missed 
labor, 401; cardiac lesions in, 294; 
cephalometry from length of, 186; 
cerebral diplegia of, 295; cerebrospinal 
meningitis of, 2S9; changes in struc- 
tures of, 305, due to abnormal te- 
nuity of amnion. 213, due to hemor- 
rhage of umbilical cord, 256, due to hy- 
datidiform mole, 210, due to placenta 
praevia, 230, due to placental disease, 
219, due to plastic exudation of am- 
nion, 212, due to syphilis, 247, 248, 
paternal causes of, 304; cholera of, 287; 
chorea of, 295; circulation of, 79, char- 
acteristic features of, 82 ; circumferences 
of trunk of, 469 ; congenital hydroceph- 
alus of, 274; cystic kidneys of, 296; 
death of, 304-306; decapitation of, 616; 
definition of word, 77; deformities and 
monstrosities of, classification of, 259; 
delivery of, in Cesarean section, 1086; 
development of, in different months of 
gestation, 85, 86, 88, 89; development 
of lanugo of, 85; diameters of head of, 
464—466; diameters of trunk of, 468; 
diseases of alimentary tract of, 295; dis- 
eases of nervous system of, 295; disease 
of urogenital apparatus of, 296; disloca- 
tions of, 301; doubled, in shoulder pre- 
sentation, 595; ductus arteriosus of, 81; 
ductus venosus of, 81; dyscrasic condi- 
tions of, 294; ears of, formation of, 84; 
effect of, maternal alcoholism on, 293, 
arsenical poisoning on, 293, arsenicism 
on, 293, cancerous cachexia on, 294, car- 
diac diseases on, 294, displacement of 
uterus on, 303, eclampsia on, 294, 348, 
fevers on, 304, jaundice on, 366, leuke- 
mia on, 294, mercurialism on, 293, mor- 
phinism on, 293, nicotinism on, 294, 



1124 



INDEX. 



phosphorus poisoning on, 293, plumbism 
on, 293, renal disease on, 294, uterine 
disease on, 303; elimination of carbon 
dioxid by, 79; embryotomy upon dead, 
10 1 1, upon living, 10 12; endocarditis of, 
294; erysipelas of, 286; ether poisoning 
of, 292; estimate of age of, 82-89; 
excretion of urine by, 66, 67; expres- 
sion of, 1033; extraction of, in low for- 
ceps operation, 1065; eyes of, formation 
of, 84; fatty degeneration of, in ectopic 
gestation, 410; false fontanelles of, 462; 
fontanelles of, 461 ; foramen ovale of, 81, 
82 ; fractures of, 301 ; giant, 618; hair of, 
origin of, 85; head of, 458-468; heart of, 
81; heart sounds of, in pregnancy, 131, 
132, 133, position of, in vertex presenta- 
tion, 514; hepatic vein of, 81 ; hereditary 
predispositions of, 296; hydrocephalus 
of, 274; hypertrophic stenosis of py- 
lorus of, 295 ; hypogastric arteries of, 81, 
82 ; icterus of, 295 ; infectious diseases of, 
285-292; influenza of, 288; kidney ex- 
cretion of, 79; lanugo of, 85; length of, 
469, in different months, 88, 89, in 
different weeks, 151; lithopsedion, 389; 
local treatment of, for syphilis, 292; 
maceration of, 305; malaria of, 287, 379; 
maternal influence over, 195; measles 
of, 386; measurement of, 472; me- 
conium, appearance of, 85; metabolism 
of, 79; movements of head upon spinal 
column of, 462; mummification of, 305, 
in ectopic gestation, 410, in missed 
labor, 415; nails of, formation of, 84; 
nephritis of, 296; nose of, formation of, 
84; nucleated red blood corpuscles of, 
79; oedema of, 301-303; over-size of, 618; 
ovoid, 471; oxygen absorbed by, 79; 
palate of, formation of, 84 ; palpation of, 
in pregnancy, 130, 131 ; papyraceus, 147, 
148; parotitis of, 289; peculiarities of 
circulation of, 81; peritonitis of, 295; 
pertussis of, 289; photography of, 190; 
planes and circumferences of head of, 
466 ; planes of trunk of, 469 ; posi- 
tions of, in vertex presentations, 514; 
posture of, 470; premature expul- 
sion of, in multiple pregnancy, 148; 
premature ossification of skull of, 618, 
indication for premature delivery, 957; 
presentation of, 471-475; primitive 
jugular vein of, 81; pulmonary artery 
of, 81; pupillary membrane of, dis- 
appearance of, 85; putrefaction of, 306, 
in missed labor, 416; rachitis of, 299, 
687; regions and protuberances of head 
of, 459; relapsing fever of, 289; re- 
tention of dead, in ectopic pregnancy, 
410; rheumatism of, 289; sanguino- 
lentus, 305, 388; saponification of, 306; 
scarlatina of, 286, 379; signs of ma- 
turity of, 86; skin diseases of, 297-299; 
sutures of head of, 460; syphilis of, 290- 
292; teeth of, formation of, 84; tem- 
perature of, 847 ; testicles of, descent of, 
into scrotum, 85; traumatisms of, 300; 
trunk measurements of, 453; tubercu- 
losis of, 289; typhoid fever of, 287; ty- 
phus of, 289; vaccinia of, 286; varicella 
of, 289; variola of, 286; vense cava? of , 81; 
ventricles of, 81 ; vernix caseosa of, origin 



of, 85; viable after maternal death, 729; 
vitality of, in different months, 85, 86; 
weight of, 469, 850, in different months, 
88, 89, in different weeks, 151; wounds 
of, 300, 301; yellow fever of , 289. 

Fever, due to constipation, 811; due to 
intercurrent and complicating disease 
in puerperium, 804, 805; due to reflex 
irritation, 814, 815; inanition, 906; in 
convulsions of newly born, 923; in 
infantile cachexia, 924; in neurotic 
conditions, in puerperium, 811, 812, 
treatment of, 817; in pregnancy, 418; in 
puerperal infection, 821, 822; in septic 
infection of newly born, 907 ; in tetanus 
of newly born, 912; maternal, effect 
of, on fetus, 304; non-septic, 810-814; 
pseudo-, in puerperium, 810, 811; 
puerperal, classification, 771; defined 
by Semmelweis, 152; in puerperal 
phlebitis, 802, 803; in pyemia, 809; 
in sapremia, 806; in septicemia, 809; 
"one-day," 783,822; in retro-displace- 
ments, of puerperal uterus, 814; resorp- 
tion, 822; in rupture of the uterus, 813, 
814; true puerperal, 814. 

Fibrin, increase of, in blood, in pregnancy, 
120. 

Fibroids, cause of intra-partum hemorrhage, 
730; in pregnancy, 315. 

Fibroma, diagnosis of, from pregnancy, 137; 
fetal, 301; of virgin uterus, 39; pelvic, 
696. 

Fibrous tissues, changes of, in pregnant 
uterus, 109. 

Fillet, 983; as tractor, 1078; in breech 
extraction, 1041; soft, 1078-1080. 

Finger-nails, care of surgeon's, 154, 155, 

t.. I56 ' 

Fistula, vaginal, diagnosis of, 1098; vesical 

and rectal, repair of, 1098. 

Fixation abscess in puerperal infection, 818. 

Flat pelvis, 689; induction of premature 
labor in, 957. 

Flat rachitic pelvis, 689. 

Flatulence in pregnancy, 118. 

Flesh moles, 388. 

Flexion, 446; incomplete, 552-555; in ver- 
tex presentation, 502, 509, 512; of head 
in breech, 584; in brow, 559, 560; in 
face presentation, 570. 

Floating kidney in pregnancy, 141, 662. 

Flooding. 633. (See Post-partum hemor- 
rhage.) 

Flow, 20. 

Follicles, arrangement of, in ovary, 44; 
sebaceous, in pregnancy, 91. 

Fontanelles, false, 462; fetal, 461; of newly 
born, 851. 

Food, in- prematurity, 869-871; in puerperal 
infection, 817; in relation to sexual func- 
tions, 37. 

roods, patented or proprietary, for newly 
born, 860. 

Foot and hand, differential diagnosis of, in 
pelvic presentation, 589. 

Foot and shoulder traction in breech pres- 
entation, 1050. 

Foramen, ischio-pubic, 427; ovale, 81, 82, 
persistent, 278. 

Forceps, 1054-1078; action of, 1057; antero- 
posterior, 1056; application of, cephalic, 



INDEX. 



1125 



1066, 1068, pelvic, 1069; as rotators, 
1073; axis-traction, 1056; in high opera- 
tion, 1070, Breus's, 1056; cause of rup- 
ture of vagina, 651; Chamberlen's, 
1054; classification of, 1058; cranioto- 
my, 1024; delivery, posture in, 946, 
947; description of, 1055. 1056; Elliott's, 
1056; facial paralysis due to, 890; high, 
1069-1071, in pelvic deformity, 716; 
high, median, low, 1059; historical, 
1054; in after-coming head, 105 1, 
107 4- 1076; in asphyxia neonatorum, 
884; in breech extraction, 1042; in 
breech presentation, 590; in brow pres- 
entation, 560, 1077; in cancer of uterus, 
668; in congenital hydrocephalus, 620; 
in deep transverse head, 1077; in de- 
layed labor, 630; in dorsal displace- 
ment of arm, 574; in dystocia due to 
affections of fetal trunk, 621 ; in eclamp- 
sia, 356; in elderly primiparae, 725; in 
face presentation, 570, 1076, 1077; in 
funnel-shaped pelves, 683; in interlock- 
ing of fetal heads, 614; in kyphosis, 
705; in mento-posterior positions, 1076; 
in obstructed labor due to levator ani, 
670; in occipito-posterior positions, 
1072, in high cases, in medium cases, 
in low cases, 1072, 1073; in occlusion 
of external os, 667; in over-developed 
fetus, 618; in pelvic deformity, 718, 720— 
724; in pelvic presentation, 1074; in per- 
sistent mento-posterior positions, 605, 
606; in persistent occipito-posterior 
positions, 601, 602; in prolapse of anus, 
573; in prolapse of umbilical cord, 
57S; in rupture of uterus, 646; in 
scoliosis, 706; in short cord, 614; in 
threatened rupture of uterus, 645; in 
transverse engagement of head in 
inlet., in deformed pelves, 608; in trans- 
verse position of head at pelvic out- 
let, 609; in vaginismus; 668; indica- 
tions, 1060, 1061; low, technique of, 
1063-1067; extraction, of fetus, 1065, 
1066, general principles of, 1066, 
median, 1068; Naegele's, 1056; opera- 
tions, frequency of, 1059, high, ordin- 
ary forceps, 1069, axis-traction forceps, 
107 1, preparation for, 1062, 1063, 
technique of, 1063-1078; Penoyee's, 
1056; placental, in abortion, 402; pre- 
requisites and contraindications, 106 1, 
prognosis of, 1062; Scanzoni's man- 
oeuvre, 1077; Simpson's, 1056; slip- 
ping of , 1062; Smellie's, 1054, steriliza- 
tion of, 1063; straight, 1056; Tarnier's 
1055, 1057. 

Fore-coming head, manual extraction of, 
1036. 

Foreign substances, removal of, from air- 
passages, in asphyxia neonatorum, 
884. 

Formaldehyde solutions, intravenous infu- 
sion of, in puerperal infection, 818. 

Formulae, for home modification of milk, 
857; for solution for umbilical infusion, 
888. 

Foster on" bipolar podalic version, 995. 

Fourchette, rupture of, 654; tears, repair 
of, nco. 

Fournier's statistics of infantile syphilis, 876. 



Fractures, fetal, 301; of cranial bones at 

birth, 893 ; of facial bones at birth, 894; 

of long bones at birth, S93, S95; of 

pelvis, anomalies due to, 696. 
French or open method of symphyseotomy, 

1009 
Friedlander's theory of decidual origin, 47, 

48. 
Frontal protuberance, fetal, 460. 
Functions of pelvic joints, 426. 
Fundus, care of, in third stage of labor, 

543-545 ; height of, in puerperium, 741 ; 

in different months of pregnancy, 150; 

pressure on, in labor, 540. 
Funis. (See Cord.) 
Funnel-shaped pelvis, 679; symphyseot- 

omv in, 1006. 



Gait, change of, in pregnancy, 122. 

Galactocele, 834. 

Galactogogues, 745, 826. 

Galactorrhea, 745, 82 7. 

Galbiati's operation of triple pelviotomy, 



Ganglia, nervous, origin of, 



61. 



Gangrene in puerperal thrombosis and em- 
bolism, S3 4. 

Gangrenous stomatitis of newly born, 909. 

Gas-bacteriemia, 810; gas sepsis, 810. 

Gastro-enteritis of newly born, 910. 

Gastro-intestinal infection of newly born, 909, 
910. 

Gastro-intestinal symptoms in phlegmasia 
alba dolens, 803. 

Gavage in marasmus, 906; in prematuritv, 
829. 

Genital organs, deformities of, clinical sig- 
nificance of, 319; disease of, 41; mal- 
formations of, in pregnancy, 315-321; 
origin of, 61. 

Genitals of child and adult, differences be- 
tween, 35; external, in pregnancy, 91, 
in puerperium, 737, 738. 

Germ-layers, formation of, 51; inversion 
of, 64; organs derived from, 61; tissues 
derived from, 61. 

Gestation, ectopic, diagnosis of, from preg- 
nancy, 140; protracted, 148, 149. 

Gestational, insanity, 37S; melancholia, 
mania, and dementia, 375-378; neu- 
ralgias, 378; paralyses, 377, 378. 

Giant pelvis, 684. 

Gingivitis in pregnancy, 364. 

Glands, decidual, 47, 48; inflammation of 
Montgomery's, 827; lymphatic, changes 
of, in pregnancy, 119; mammary, 
origin of, 61; mucous, vaginal, in preg- 
nancy, 91; origin of, 61; pelvic, 450; 
salivary, origin of, 61, 84, in preg- 
nancy, 365; sweat, in pregnancy, 91, 
121; thymus, origin of, 61; uterine, 
changes in, in menstruation, 21; 
uterine, in pregnancy, 78; vaginal, 
91 ; vulval, 91. 

Globule, polar, 44. 

Gloves, rubber, 157; sterilization of, 159. 

Glycerin, intrauterine injection of, to induce 
abortion, 960, 961. 

Glycosuria in pregnancy, 362; in puer- 
perium, 362. 



1126 



INDEX. 



Goitre, congenital cystic, cause of dystocia, 

620; in pregnancy, 371. 
Gonococcus, in puerperal infection, 153, in 

ophthalmia neonatorium, 898, 900. 
Gonorrhea, cause of ante-partum hemor- 
rhage, 418; puerperal, 793, 804, 805. 
Gonorrheal stomatitis, 902. 
Gooch's method of bimanual compression of 

uterus, in post-partum hemorrhage, 639. 
Goodell's cases of accidental hemorrhage, 

241. 
Gottengen's weights of embryo and fetus, 

86, 88, 89. 
Graafian follicle, causes of rupture of, 17; 

development of, 17; formation of, 17; 

mature, 17; number rupturing in a 

year, 19; obliteration of unruptured, 

19; time of rupture of, 17. 
Granule, seminal, 28. 

Granuloma, infectious, of placenta, 247, 248. 
Gravitation theory of presentation, 474. 
Gynecological disease, causes of, 37. 



Habitual death of fetus, 957. 

Hair, in pregnancy, 121; origin of, 61, 85. 

Hamilton's method of abortion, 961. 

Hand, choice of internal, in cephalic pres- 
entation, 1000, in internal podalic 
version, icoo, in shoulder presentation, 
1003, in internal podalic version, 1003; 
diagnosis of, from foot, 589, 1002; dis- 
infection, 156, 157, 158, 159, 520; origin 
of, 61. 

Hanging belly, 307. 

Head, fetal, 458-468; after-coming (see 
After-coming head) ; cephalotribe to, 
1024; changes in shape of, in anterior 
parietal presentation, 571; in bregma 
presentation, 553-554, in brow presen- 
tation, 556, in face presentation, 564, 
570, in persistent occipito-posterior po- 
sition, 599; delivery of, 532-538; in per- 
sistent sacro-posterior cases, 1051-1054; 
detached, forceps to, 1075; engagement 
and descent of, in vertex presenta- 
tion, 505, 506; excessive flexion of, 
551; first cases, shoulder extraction 
in, 1037; fore-coming (see Forecom- 
ing head); incomplete flexion of, 552- 
555; interlocking, 614; location of, 
in pregnancy, 164, 165, 166; manual 
engagement of, 188; manual rotation 
of transversely placed, in breech pres- 
entation, 1046; oversize of, 618; per- 
foration of, in after-coming, 10 15, in 
brow presentation, 560; prevention of 
too rapid advance of, in labor, 532- 
538; rotation of, in breech cases, 497; 
transverse engagement of, in inlet in 
deformed pelves, 605; transverse posi- 
tion of, at pelvic outlet, 608, 609. 

Head of newly born, shape of, 851. 

Headache in pregnancy, 378; in eclampsia, 
347; in puerperal infection, 821; in 
sapremia, 806. 

Health, in pregnancy, 120; in relation to 
sexual functions, 37; menstruation as 
related to, 25. 

Hearing, affections of, in pregnancy, 119. 



Heart and vessels in fetal syphilis, 291. 

Heart, beginning of function of, 84; changes 
in, in pregnancy, 118, 119; develop- 
ment of, 79; disease of, indication for 
prevention of reproduction, 39, dysto- 
cia due to, 727, vaginal Cassarean sec- 
tion in, 1088, heart disease of (endocar- 
ditis), infrequency in pregnancy, 368; 
failure, posture in, 946; fetal, 81, 
location of, 167; hypertrophy of, in 
pregnancy, 119; in puerperium, 737; 
murmur of, in puerperium, 734; muscle. 
affections of, in pregnancy, 369; of 
newly born, 920; origin of, 78; rate of 
fetal, 167. 

Heartburn in pregnancy, 118, 366. 

"Heat" and menstruation, relation be- 
tween, 23. 

Heat, as a means of sterilization, 928; 
a stimulant to sluggish uterus, 628; 
flashes in menopause, 27; in atelectasis, 
904 ; in caked or overdistended breasts, 
813, 827; in colic of newly born, 920; 
in convulsions of newly born, 923; in 
galactocele, 834; in malignant perit- 
onitis, 802; in puerperal parametritis, 
796; in pulmonary embolism, 841; in 
relation to spermatozoa, 28. 

Hegar's, dilator, 971 ; sign, in pregnancy, 125. 

Hematemesis in labor, 728. 

Hematocele, extrauterine and extraperito- 
neal, 642; in pregnancy, 369; origin 
of, 410; pelvic, diagnosis of, from preg- 
nancy, 139. 

Hematoma, cause of dystocia, 670; of 
placenta, 243-246; of sternomastoid, 
856; of umbilical cord, 256. 

Hematometra, diagnosis of, from pregnancy, 
136. 

Hematosalpinx, origin of, 407. 

Hematuria, in newly born, 916; in preg- 
nancy, 362; in puerperium, 765. 

Hemiopia, in puerperium, 837. 

Hemiplegia and aphasia, puerperal, 837. 

Hemoglobin of newly born, 849. 

Hemoglobinuria in Winckel's disease, 918. 

Hemorrhage, accidental, 237-243; after abor- 
tion, 398, 399 ; after first labor in case of 
twins, 612 ; ante-partum, causes of, 418- 
420; breech extraction in. 1039; cause 
of, in placenta praevia, 226; cerebral, of 
newly-born, 889; concealed, 238, in pre- 
mature detachment of normally situated 
placenta, 238; control of, in third stage 
of labor, 490, in Cassarean section, 1086; 
curettage in, 401-403 ; due to premature 
detachment of normally situated pla- 
centa. 237-243; following rape, 35; from 
genitals in female infants, 916, types of, 
916; from umbilical cord, 256; in abor- 
tion, 397; in atony of uterus, 402; in 
Buhl's disease, 917 ; in Cassarean section, 
1087 ; in congenital S3 r philis, 875 ; in frac- 
ture of cranial bones, 893 ; in general, of 
newly born, 914-916; in hydatidiform 
mole, 2 10 ; in inversion of uterus, 647 ; in 
menopause, 41, in miscarriage, 397; in 
multiple pregnancy, 148; in paralysis of 
placental site, 637; in placental polypi, 
252; in placenta praevia, 228, 233; in 
hemorrhoids in pregnancy, 366; in pre- 
mature labor, 379; in puerperal anemia, 



INDEX. 



1127 



835; in retained placenta, 633; in rup- 
ture of fetal cyst, 409; in septic infec- 
tion of newly born, 907; in twin labor, 
612; interstitial, of placenta, 243-246; 
late, 761; partum or intrapartum, 730; 
pathological, and menstruation, confu- 
sion between, 124; periovular, 389; 
podalic version in, 993; post-partum, 
633—641, posture in, 946; prevention of, 
in third stage of labor, 543; puerperal, 
761-764; remedies in, 242, 243, 637-641; 
saline solution injections in, 929-933; 
secondary, 761, in atony of uterus, 402, 
in retained placenta, 6^,3. 

Hemorrhoids, cause of ante-partum hemor- 
rhage, 366, 418—420; in pregnancy, 366, 
treatment of, 366; in puerperium, 764; 
vesical, cause of hematuria in pregnancy, 
362; vesical, in pregnancy, 361. 

Hepatic insufficiency and morbidity of preg- 
nancy, parallelism between, 325. 

Hepatic lesions and eclampsia, relation be- 
tween, 325. 

Hepatic vein, fetal, 81. 

Hereditary predispositions of fetus, 296. 

Heredity, in multiple pregnancy, 144; in 
relation to menstruation, 23; in rela- 
tion to sex-control, 91; in relation to 
sexual functions, 37; of syphilis, 876. 

Hermaphroditism, 260, 271. 

Hernia, cause of dystocia, 661; congenital 
inguinal, 278; congenital umbilical, 273; 
due to constipation in newly born, 
921; in pregnancy, 122; of umbilical 
cord, 256; tendency to, in prematurity, 
867; vaginal, cause of dystocia, 726; 
ventral, and pregnancy, coexistence of, 
141. 

Hernial protrusion of pregnant uterus, 313. 

Herpes gestationis, 381. 

Hertz's theory of toxemia of pregnancy, 
326. 

Hick's method of bipolar podalic version, 
advantages of, 994. 

High forceps, dangers of, 1069. 

Hip, congenital dislocation of, 278. 

Hodge on planes of pelvic cavity, 435, 436. 



Holl's sign, 397. 

Hook, blunt, 1081, in breech extraction, 

1041. 
Hour-glass contraction of uterus, 633. 
Hydatidiform mole, 208-211. 
Hydatids, uterine, 208. 
Hydraemia in pregnancy, 370. 
Hydramnios, 66, 215-219; acute, 215-219; 

and nevi, relation between, 67 ; chronic, 

symptoms of, 216, treatment of, 218. 
Hydrencephalocele, 275, 897; cause of 

dystocia, 620. 
Hydrocele, congenital, 278. 
Hydrocephalus, congenital, 274, 618, 619; 

diagnosis of, 274, 618, 619; etiology of, 

275; internal, 275; of newly born, 876; 

pathology of, 274; prognosis of, 619; 

treatment of, 619. 
Hydrometra, diagnosis 'of, from pregnancy, 

136. 
Hydronephrosis, cause of dystocia, 621; in 

pregnancy, 326. 
Hydrophobia in pregnancy, 289. 



Hydrorrhea, amniotic, 214; gravidarum, 
201. 

Hydrosalpinx and pregnancy, coexistence 
of, 141. 

Hydrostatic, bags of de Ribes, 960; cervical 
bags in placenta prsevia, 236. 

Hydrotherapy in puerperal infection, 817. 

Hydrothorax, congenital, cause of dystocia, 
620. 

Hygiene and management of newly born, 
851-862. 

Hygiene of pregnancy, 191; of the puerper- 
ium, 815; of sexual functions, 37. 

Hygienic measures preparatory for puer- 
perium, 815. 

Hygroma, cystic, cause of dystocia, 620. 

Hymen, after rape, 36; annular, 31; carun- 
culas myrtiformes of, 738 ; congenital, ab- 
sence of , 3 1 ; definition of, 31; deformities 
of, 320; diaphragmatic, 31; forms of, 
31; healing of ruptured, 35; imperfor- 
ate, 31; injury of, 31; in a child, 35; 
persistent, cause of dystocia, 670; pre- 
served, 31; rupture of, 31; semilunar, 
3 1 ; sign of virginity, 3 1 . 

Hyperemesis gravidarum, 366. 

Hyperinosis, in pregnancy, 120; in puer- 
perium, 737. 

Hyp erin volution in puerperium, 768. 

Hyperlactation, 827. 

Hypermetropia, 277. 

Hyperosmia in pregnancy, 371. 

Hyperpyrexia neonatorum, 905. 

Hyperthermia, from reflex irritation, 811- 
814; puerperal, nurotic, 814; puerperal, 
simple, 822; simple, 810, 811. 

Hypertrophy, congestive, of uterus, diag- 
nosis of, from pregnancy, 138; of 
placenta, 222. 

Hypnotics in psychoses of pregnancy, 377. 

Hypodermoclysis, 932, 933. 

Hypogastric arteries, fetal, 81, 82/ 

Hypophysis, 56; origin of, 61. 

Hypoplasia uteri, 319. 

Hypospadias, 273. 

Hypothermia, puerperal, 814, 815. 

Hyrtl's table of insertion of umbilical cord, 
252, 253. 

Hysterectomy, supravaginal, 1089, 1090; in 
cancer of uterus, 668; in deciduoma 
malignum, 208; in osteomalacia, 695; in 
puerperal infection, 819, 820; in rup- 
ture of uterus, 1097; in sapremia, 
823. 

Hysteria, after labor, 636; cause of fever, 
in puerperium, 814; diagnosis of, from 
eclampsia, 349; following rape, 35; in 
pregnancy, 378. 

Hysterical mother, offspring of, 875. 



I. 

Ice, use of, in hemorrhage, 242, 640. 

Ice-bag, in puerperal infection, 817. 

Ichthyol, in umbilical infection, 908 ; in phleg- 
masia alba dolens, 804; in puerperal 
infection, 819; ointment in erysipelas, 
813, in mastitis of newly born, 918, in 
Ritter's disease, 910, in septic pemphi- 
gus, 910; solution in subcutaneous mas- 
titis, 829. 

Ichthyosis congenita, 297, 298; fetal, 875. 



1128 



INDEX. 



Icterus gravidarum, 344, 366, 367; in septic 
infection of newly born, 907; neona- 
torum, 295, 914, 918. 

Idiocy due to fetal cerebral hemorrhage in 
labor, 890. 

Idiosyncrasies, mental, in pregnancy, 195, 
196, 376. _ m 

Iliacus muscle, description of, 445. 

Ilio-pectineal eminence, definition of, 432. 

Ilio-pectineal line, definition of, 432. 

Ilium, 423. 

Impaction, of breech, in pelvic cavity, 1042; 
of fetus in labor, 510, 511. 

Imperative conceptions in pregnancy, 376. 

Imperforation of vagina, cause of dvstocia, 
668, 669. 

Impetigo contagiosa neonatorum, 910, 911. 

Impetigo herpetiformis, 382; cause of sud- 
den death in pregnancy, 416. 

Impregnation, 27, 44; artificial, 29, 30; from 
rape, 36; definition of, 27; relation 
between menstruation and, 29; subse- 
quent to delivery, 747; synonyms of, 
27; time of, 30; time most favorable 
for, 29; unconscious, 30. 

Inanition fever, 906. 

Inanition of newly born, 905. 

Incarceration of pregnant uterus, 307, 309- 
312. 

Incision, in cancer of uterus, 668 ; in dystocia 
due to hematoma, 670; in dystocia due 
to oedema, 670; in mastitis, 832; in oc- 
clusion of external os, 667; in pro- 
tracted labor, 630; in rigidity of os, 
655; in vaginal obstruction, 670; in 
vaginismus, 668; vagino-perineal, 979, 
of cervix, vagina, and vulva, 975-980, 
of vagina, 978. 

Inclination, pelvic, 426. 

Incontinence of urine, causes of, 360; in 
pregnancy, 360; in puerperium, 765; 
diagnosis of, from hydrorrhcea gravi- 
darum, 201. 

Incubator, Denuce's, 871; for atelectasis, 
905; dangers, 872; in prematurity, 869; 
Lion, 871; proper temperature of, 872, 
873; Tarnier's, 871. 

Indigestion, gastric and intestinal, in preg- 
nancy, 118, 366. 

Inertia, abdominal, 625, 626; partial, 626; 
primary, 622 ; primary uterine, 625, 626; 
secondary, 622; secondary uterine, 625, 
626; cause of intra-partum hemorrhage, 
730, forceps in uterine, 106 1. 

Infant feeding, 852-861. 

Infant, first care of, 851; rape -upon, 35. 

Infantile, atrophy, 924; cachexia, 923; mor- 
tality, 914; paralysis, 890. 891; pelvis, 
439- 676. 

Infarction of placenta, 243, 246, 248. 

Infarcts, subchorial, of placenta, 249; white, 
of placenta, 249, 250; yellow, in living 
infant, 79. 

Infection, consecutive focal puerperal, 792- 
805; primary, focal, 781-792; septic, in 
interrupted pregnancy. 39S. 

Infectious diseases, in pregnancy, 378-380; 
of newly born, acute, 873, 874, chronic, 
874, 8 75 . 

Inferior vena cava, fetal, 81. 

Inflammations, genital and extra-genital, 
in puerperium, 773, 774. 



Inflation in intestinal obstruction of newly 
born, 922. 

Influence, maternal, on fetus, 195. 

Influenza, in newly born, 874; in pregnancy, 
288; in puerperium, 813; of fetus, 288. 

Infusion, saline, in post-partum hemorrhage, 
640; intra-arterial and intravenous, 930, 
rectal, 929. 

Injuries, and accidents in pregnancy, 416, 
417; operations for correction of, 417, 
1097-1103; to cervix, vagina, rec- 
tum, perineum, and clitoris, repair 
of, 1 098-1 103; to cranial bones at 
birth, 893; to placenta, 237-243; to 
scalp at birth, 895-897. 

Inlet, pelvic, anatomical, 430; axis of, 430; 
circumference of, 432 ; definition of, 430; 
measurements of, 430; obstetric land- 
marks of, 432; obstetric boundaries of, 
430; shape of, 430; transverse diameter 
of, 178, 181. 

Innominate bone, 423. 

Insanity, gestational, 378; indication for pre- 
vention of reproduction, 39; of labor, 
727; of lactation, 83S; of pregnancy, 
375-377; of puerperium, 837-839. 

Insemination, 27; and menstruation, rela- 
tion between, 27; definition of, 27; 
phenomena of, 27. 

Insertio velamentosa, 223. 

Insomnia in puerperal infection, 821; in hy- 
dramnios, 217; in pregnancy, 377. 

Instrumental curettage, 1096, 1097; dilata- 
tion of cervix, 969-973; extraction of 
placenta, 1094. 

Instruments for curettage, 1096, 1097; for 
obstetrical operation, 928; for pelvic 
floor lacerations, 1100, 1 10 1 ; for repair 
of cervix, 1098; obstetric, asepsis of , 815, 
816. 

Insufflation in asphyxia neonatorum, 888. 

Intercourse, sexual, stages of, 40. 

Intercrestal diameter of pelvis, measure- 
ment of, 429. 

Interlocking of fetal heads, 614. 

Internal cephalic version, 992; operation of, 
method of D'Outrepont, 992, method of 
Busch, 993, Vienna method, 993. 

Internal podalic version, 997-1004. 

Interspinous, anterior diameter of pelvis, 
428; posterior diamter of pelvis, 429. 

Interstitial pregnancy, pathology of, 408; 
tubal pregnancy, 404, 405. 

Intestinal anomalies in puerperium, 764; 
obstruction of newly born, 922. 

Intestines, topographical relations of, at 
term, 115. 

Intramural pregnancy, pathology of, 408. 

Intra-partum, affections, 878-903 ; eclampsia, 
348; hemorrhage, 706; infection, 898- 

9°3- 
Intraperineal lacerations, 652. 
Intrauterine and extrauterine pregnancy, 

coexistence of, 405. 
Intravenous infusion of saline solution, 930, 

93i- 

Intussusception in newly born, 922. 

Inunction in infantile syphilis, 877. 

Inversion of uterus, 647, cause of intra- 
partum hemorrhage, 730. 

Inverted pelvis, 685. 

Involution, 739, 740; disturbed, in puerperal 



INDEX. 



1129 



infection, 821, 822; effect of nursing on, 

Iodine, m endometritis, 791 ; in puerperal in- 
fection, 818; in umbilical infection, 908; 
in puerperal ulcers, 782; in phlegmasia 
alba dolens, 804. 

Irrigation, after abortion, 408; after manual 
extraction of placenta, 1095; for in- 
strumental curettage, 1096; in puer- 
peral parametritis, 796 ; vaginal, in puer- 
peral endometritis, 790-792. 

Irritability, mental, in pregnancy, 194, 195. 

Ischio-bulbosus muscle, 448. 

Ischio-pubic foramen, 427. 

Ischio-pubiotomy, double, 1005; unilateral, 
1005, in Naegele's pelvis, 683. 

Ischium, 424. 

Isolation in cancrum oris, 909; in erysipelas 
of newly born, 912; in ophthalmia neo- 
natorum, 900; in puerperal pemphigus, 
808; in septic infection, 908. 

Isthmial pregnancy, 405. 

Italian method of symphyseotomy, 1008. 



J. 

Jacquemier's sign in pregnancy, 128. 

Jaundice in newly born, 918, 919; in preg- 
nancy, 367; fatality of epidemic in 
pregnancy, 325. 

Jaw-and-shoulder traction in breech pres- 
entation, 1049. 

Jaw, fracture of lower, at birth, 894. 

Joints, amphi-arthrodial, origin of, 61 ; pelvic, 
424-426; origin of, 61; changes of, in 
pregnancy, 117; pubic, 424; rupture of, 
in labor, 673; sacro-coccygeal, 426; 
sacro-iliac, 425, movements in, 426; 
sacro- vertebral, 426; synovial, origin 
of, 61. 

Jugular vein, primitive, 81. 

Justo-major pelvis, 684; symphyseotomy in, 
1006. 

Justo-minor asquabiliter pelvis, 676. 



Keratolysis exfoliativa, 298. 

Kidney, affections of, in elderly primiparas, 
724; congenital cystic degeneration of, 
cause of dystocia, 620; cystic, eviscera- 
tion in, 1030; development of, 79; ex- 
cretion of fetal, 79; floating, cause of 
dystocia, 662; floating, and pregnancy, 
coexistence of, 141, 358; functional 
development of, 79; effect of hepatic 
insufficiency on, in pregnancy, 326; 
incarceration of, in pregnancy, 358; 
infarcts of, in infants, 79; in fetal 
syphilis, 291; in puerperium, 736; 
origin of, 60; pregnancy, 325, 326, 328; 
tumors of, in pregnancy, 358; "specific" 
forpegnancy, 325, 328; wandering, diag- 
nosis of. from pregnancy, 140. 

Knee and elbow, differential diagnosis of, 
1002; in pelvic presentation, 589. 

Knee-chest posture, 940; indications for, 
941; in version, 942. 

Knots in umbilical cord, 73, 253. 

Korsakoff's psychosis, 835. 

Kyphoscoliosis, 707. 

Kyphosis, 702-705. 



L. 

Labia, in pregnancy, 91. 

Labor, abdominal binder after, 548; acute 
psychosis during, 727; after operations 
involving genitals, 657-659; after vag- 
inofixation, 658; anesthesia in, 933-936; 
anesthetics in, 532, 535, 542; anesthesia 
as an aid in diagnosis in, 935; ante- 
partum bath, 524; antepartum enema, 
524; ante-partum vaginal irrigation, 
524; antipyrin in, 935; arterial tension 
in, 481; asepsis in, 516; asystole in, 727; 
auxiliary forces in, 478; bacterial 
changes produced by, 775-779; bed in, 
522 ; bimanual dilatation in delayed first 
Stage of, 966, 967; caput succedaneum 
in, 489, 504; cause of onset of, 482 ; cer- 
vical dilatation in, 453, 485; cervical 
dilatation in primiparas and multiparas 
in, 454; cervical shortening in, 483; chill 
after, 490; chloral in, 935; chloroform 
in, 933; chloroform in, fetal asphyxia 
from, 292; cleansing of patient and bed 
after, 548; conduct of, first stage of, 530, 
second stage of, 530, third stage of, 543 ; 
death during, 728; deep transverse posi- 
tion in, 496; definition of, 423; delirium 
of, 727; delivery of body in, 540; de- 
livery of head between uterine contrac- 
tions, 532, 534, 538; delivery of mem- 
branes, 543; delivery of placenta, 543; 
delivery of shoulders, 538; dilatation of 
internal os, 483; discharge during, 484; 
dry, 626; duration of, limited, 515; dur- 
ation of normal, 499; effect of eclamp- 
sia on, 348, 349; engagement and des- 
cent during, 492; entrance of air into 
uterine sinuses in, 842 ; episiotomy in, 
978; ergot after, 547; ether during, 933; 
ether in, fetal asphyxia from, 292, 293; 
etiology of, 482; examination in, 525- 
530; examination of placenta and mem- 
branes, 545; expelling forces in, 478; 
expulsion of first part of fetal ellipse 
during, 496, 497; expulsion of head in 
normal, 506, 509, 54; expulsion of 
second part of fetal ellipse during, 
498; expulsion of trunk in, 508, 509, 
512; extension of head in normal, 507, 
509; external examination in, 525, 526; 
factors concerned in, 423; false, and 
time of its appearance in ectopic gesta- 
tion, 410; false contractions or pains 
before, 481; false pains distinguished 
from true, 483; feigned delivery, 499; 
fetal impaction during, 511; first stage 
of, 484-488, bladder and rectum during, 
530, care of membranes during, 531, food 
and drink during, 530, limits of, 530, 
presence of physician during, 530, sleep- 
ing during, 530, vaginal examination 
during, 530, voluntary forces during, 
531 ; flexion of head in vertex presenta- 
tion, 502,509, 5 1 2 ; head delivery during, 
532-538; head rotation in breech cases 
during, 497; hematemesis during, 728; 
hemorrhage during third stage of, 489; 
immature (see Miscarriage) ; incomplete, 
774- 775» contraction and retraction 
in, 774, drainage in, 775; indications for 
induction of premature, 959, 960; in 



1130 



INDEX. 



elderly primiparas, 724, 725; induction 
of premature, in pelvic deformity, 721; 
induction of, for placenta praevia, 232- 
237; induction of, in pernicious vomit- 
ing of pregnancy, 342; insanity of, 727; 
inspection and repair of perineum after, 
542; internal examination in, 526-530; 
internal rotation of trunk during, 497; 
involuntary forces in, 479; lighten- 
ing during, 483; limiting duration of, 
515; live birth, 499; local anesthesia 
during, 896; lying-in room, 522; man- 
agement of, 514, first stage of, 530, 
second stage of, 531-543, third stage 
of, 543-548, triple, 613, twin, 610-613, 
with placenta praevia, 233; means for 
accelerating first stage of, 628-630; 
mechanism of, 490-498, in breech 
presentations, 581, in brow presenta- 
tions, 556, in deep transverse position, 
496, in face presentation, 560—571, in 
vertex presentation, 501-514; menin- 
gitis during, 727; metrorrhagia of, 730; 
missed, 415; morbid conditions result- 
ing from, 774-779; morphia during, 935, 
936; mother's outfit for, 516-524; mould- 
ing during, 492 ; moulding of head in ver- 
tex presentation, 503-505, 509-512; nor- 
mal, 423; nourishment, rest and sleep 
after, 548; obstetric nurse for, 522; ob- 
structed, 623, due to levator ani, 670; 
occipito-posterior position, right, con- 
version of, into face presentation, 511; 
pains of, 479-482 ; pathological, 551, 730; 
perineal protection in, 532-540; perni- 
cious vomiting during, 728; physiologi- 
cal, 423 ; physiological chill in, 490; pla- 
cental delivery, 490; posture as an aid 
in, 944-947 ; positions in vertex pres- 
entations, 501; position of fetal heart 
sounds, in vertex presentation, 514; 
position of fetus, in vertex presenta- 
tion, 514; posterior rotation and birth 
of occiput over perineum in, 509-512; 
posterior rotation and impaction, 511; 
post-partum douche, 457; posture in, 
53° _ 53 2 > 93 6 , 944-946; precipitate, 623- 
625; preliminary preparations for, 516; 
preliminary vulval dressing after, 542; 
premature, 385, induction of, 956-963, 
preparation for, 548; preparation of 
patient for, 523-530; presence of 
physician after, 548; preservation of 
perineum during delivery of shoulders, 
53 8 > 539; pressure on fundus during, 
540; prevention of hemorrhage during 
third stage of, 543; prevention of too 
rapid advance of head, 532; prolonged, 
623, in contracted pelvis, 713; prophy- 
laxis of, 515; protracted, 625-630; pul- 
monary embolism in, 841 ; pulse in, 481 ; 
respiration during, 481; response to 
summons to, 523; retention of secun- 
dines, 545 ; rubber gloves in, use of, 157 ; 
rupture of membranes in, 485; rupture 
of spleen during, 728; second stage of, 
489; second stage of. bladder and rec- 
tum during, 531, food and drink during, 
531, limits of, 531, membranes rup- 
tured artificially during, 532, perineal 
protection during, 532-540, presence of 
physician during, 532, sleep during, 532, 



vaginal examination during, 532, volun- 
tary forces during, 532; shoulder de- 
livery, 508; show in, 481, 485; six 
stages of mechanism of, 49 1 ; spinal 
anesthesia during, 936; spontaneous, 
in placenta praevia, 233; stages of, 483- 
491; stage of dilatation in, 484-487; 
strength of uterine contractions during, 
481; sudden death in, 728; syncope in, 
636; temperature during, 481; third 
stage of, 489, 490, 543-548, cleansing 
of patient and bed at completion of, 
548, limits of, 543, nourishment after 
completion of, 548, presence of physi- 
cian after completion of, 548, rest and 
sleep after completion of, 548, vulval 
dressing at completion of, 548 ; time 
of, 25; traumatism in, prompt surgical 
treatment of, 515; twin, mortality of, 
148; unconscious delivery in, 500; 
uterine contractions during second 
stage of, 489, during third stage, 489; 
uterine contractions in, 479; uterine 
walls during, 453-458; vaginal ex- 
amination, 528-530; vertex presenta- 
tion, diagnosis of, after labor, 514, 
during labor, 512, 513, prognosis of, 513, 
voluntary forces in, 478; vulval dressing, 
after, 548; Walcher's position during, 
947; without internal examination, 
' 53o. 

Laborde's method, of artificial respiration, 
887; of tongue traction, 884, 887. 

Lacerations and contusions of cervix, 648, 
649. 

Lacerations, cervical, repair of, 1098; of 
pelvic floor, 652-657, 1099-1103; vag- 
inal, repair of, 1098, 1099. 

Lactation, insanity of, 838, 839; pregnancy 
during, 124; in relation to psychoses 
of pregnancy, 377; menstruation sup- 
pressed during, 25. 

Lactobutyrometer, 747. 

Lactosuria in pregnancy, 362; in puer- 
perium, 736. 

Lacunas, maternal, 70. 

Langhan's layer, 69. 

Lanugo, development of, 85. 

Laparohysterectomy, 1082, 1086, in pelvic 
deformity, 722. 

Laparotomy in ectopic gestation, 413; in 
intestinal obstruction of newly born, 
922; in ovarian tumor in pregnancy, 
661; in puerperal infection, 8iq, 820; 
in puerperal malignant peritonitis, 801, 
802; in rupture of uterus, 646; in 
shoulder presentation, 579. 

Larynx, acute obstruction of, a cause of 
labor, 727. 

Latero-flexion during pregnancy, 312. 

Latero-prone posture, exaggerated, indica- 
tions for, 941, 942. 

Latero-version during pregnancy, 312. 

Lead-poisoning, effect of, on newly born, 875. 

Leaman's parturiometer, 481. 

Legs, changes in; in pregnancy, 117; choice 
of, to bring down, in internal podalic 
version, 1001, 1002; choice of, to bring 
down, in combined podalic version 
in cephalic presentation, 997, in com- 
bined podalic version in shoulder pre- 
sentation, 1003 ;■ extraction by, in breech 



INDEX. 



1131 



presentation, 1042, 1044; extraction of, 
in breech presentation, 1040, 1041; 
prolapse of, 574, 576; reposition of, 
prolapsed, 985, 987. 

Legitimacy of offspring, according to dura- 
tion of pregnancy, 149. 

Lens, crystalline, origin of, 61; optic, forma- 
tion of, 56. 

Leopold's ovum, 47. 

Leucocytes in genital tract, 153. 

Leucocytosis in pregnancy, 120. 

Leucorrhea, effects of, on vagina, 25; fol- 
lowing coitus interruptus, 40; in preg- 
nancy, 193, 321; treatment of, 193, 
194. 

Leukemia, an indication for premature de- 
livery, 958; effect of, on fetus, 294; 
in pregnancy, 294. 

Levator ani muscle, cause of obstructed 
labor, 670; description of, 445; func- 
tions of, 446, 447. 

Leverage exerted by forceps, 105S. 

Ligaments, pelvic, 448, changes of, in preg- 
nancy, 117; pubic, 425; uterine, absent, 
319, changes of, in pregnancy, 113, 
114, defective, 319. 

Ligamentum arcuatum, 425. 

"Lightening" before labor, 105. 

Limbs, development of. 53; monstrosity of , 
278, 279; origin of, 60. 

Lime concretions in placenta, 249, 250. 

Lime water as mouth wash, 364; in modi- 
fication of milk, 855, 858. 

Linea ilio-pectinea, 430. 

Linea terminalis, of pelvic inlet, definition, 

43 2 - 

Linear albicantise, in pregnancy, 121. 

Lion couveuse, 871. 

Lipuria in pregnancy, 363. 

Liquor amnii, anomalies of, 214, 218; con- 
stituents of , 66 ; functions of, 68; physi- 
cal characteristics, of 66; secretion of, 
66; theories of origin of, 66, 67. 

Lithopedion, 306. 

Lithotomy posture, exaggerated, 939, 944. 
907; in dystocia due to vesical calculus, 
672. 

Little's disease, 295. 

Live birth, 499. 

Liver, acute yellow atrophy of, and preg- 
nancy, relation between, 324; displaced, 
and pregnancy, coexistence of, 141 ; fetal, 
part taken by, in circulation, 81 ; forma- 
tion of , 57 ; in fetal syphilis. 290 ; in preg- 
nancy, 119, 325; functional paralysis of, 
326; of newly born, 849; lesions of, in 
toxemia of pregnancy, 327; origin of, 61 ; 
results of experimental operations on, 

325- 

Lochia, alba, 739; in puerperium, 738, 739, 
examination of, 75; in puerperal infec- 
tion, 822; rubra, 739; serosa, 739; vari- 
ation of, in different patients, 761. 

Lochiocolpos in the puerperium, 775. 

Lochiometria in the puerperium, 775. 

Locked twins, 614. 

Lohlein's measurement, 181. 

Longings in pregnancy, 351. 

Lordosis pelvis, 708. 

Lowenhardt's rule for calculating date of 
confinement, 150. 

Lungs, dystocia due to disease of, 727; 



formation of, 57; in fetal syphilis, 291; 
in pregnancy, 119; origin of, 61. 

I Lying-in room, 522. 

J Lymph, origin of, 61. 

J Lymphangiomata, fetal, 301. 
Lymphangitis, mammary, during puer- 
perium, 828. 

I Lymphatics, changes of uterine, in preg- 
nancy, 112; pelvic, 450. 
Lysol, in endometritis, 790; in vaginal and 
intrauterine injections, 950. 



M. 

1 Maceration of fetus, 305. 

Macula, 17. 
' Magnesia, milk of, as mouth wash, 365; 
in constipation of newly born, 922. 

Malacia, in pregnancy, 366. 

Malaria, in fetus, 287; in newly born, 874; 
in pregnancy, 287, 288, 379. 

Male pelvis, 679, 680. 

Male pronucleus, 44. 

Malformations and monstrosities of newly 
born, 873. 

Malformations, fetal, in plastic exudation 
of amnion, 213; producing dystocia, 
616-622. 

Malignant disease, after abortion, 399; of 
vagina, cause of ante-partum hemor- 
rhage, 420. 

Mall, on dimensions of ovum of twenty-seven 
days, 83 ; on embryo, 65; on neurenteric 
canal, 53; on pathological embryos, 258. 

Mammae, absence of, 825; changes in, in 
pregnancy, 118, 129, 130; hypertrophy 
of, 825. 

Mammary, abscess in newly born, 918; irrita- 
tion a cause of fever during the puerpe- 
rium, 812, 813; lymphangitis in puerpe- 
rium, 828-834. 

Mania following rape, 35; in pregnancy, 
120; in puerperium, 838. 

Manual, dilatation of cervix, 963-975; ex- 
traction of placenta, 1094, 1095. 

Marasmus of newly born, 905, 924. 

Marginal insertion, of cord, 253; of placenta 
praevia, 224. 

Marriage as related, to heart disease, 727, 
to pelvic deformity, 715, 723, to pelvic 
disease, 39, to consanguinity, cause of 
interrupted pregnancy, 276. 

Massage in agalactia, 826; in atelectasis, 
905; in caked breasts, 827; in consti- 
pation of newly born, 922; in galacto- 
cele, 834; in infantile cachexia, 924; 
in mastitis, 831; in paralysis of arm, 
893; in puerperal neuritis, 836; in puer- 
perium, 757 ; in traumatic paralysis, 837 ; 
of nipples, 828; of uterus in subinvolu- 
tion, 768. 

Mastitis, 828-834; incision in treatment of, 
832; in newly born, 918; parenchyma- 
tous, 829; puerperal, 792; treatment, 
831. 

Masturbation in relation to sexual func- 
tions, 37. 

Materna graduate glass for the modification 
of milk. 816. 

Maternal dystocia, 622-730; due to forces, 
623-630; due to general maternal con- 



1132 



INDEX. 



ditions, 724-730; due to obstructed 
labor, 659-724; in parturient tract and 
adnexa, 630-659. 

Maternal impressions, 295. 296. 

Maternity, the insanity of, 375. 

Maturity, of fetus, signs of, 86, of ovum, 44. 

Mauriceau's method in breech presentation, 
1049, a ca use of paralysis of arm, 892. 

Maxillary processes, formation of, 84. 

Measles, complicated by cancrum oris, 909; 
in fetus, 286; in newly born, 873; in 
pregnancy, 200, 286, 379. 

Measurements, fetal, 88, 89; table of pelvic 
and fetal, 472, 473. 

Mechanism of labor, 491; in breech pres- 
entation, 581-587; in bregma presenta- 
tion, 553, 554; in brow presentation, 
556, 557; in contracted pelves, 673- 
723; in coxitis, 708; in deep transverse 
position, 608; in face presentations, 
562-567; in generally contracted, non- 
rachitic pelves, 677; in Xaegele's pelvis, 
682, 683; in occipito-posterior pres- 
entation, 597; in pelvic presentation, 
581-587; in persistent mento-posterior 
positions, 603, 604; in persistent occip- 
ito-posterior position, 598, 599; in 
scoliosis, 682; in shoulder presentation, 
592-595; in simple flat, non-rachitic 
pelves, 678, 679; in transverse engage- 
ment of the head, in the inlet in gener- 
ally contracted pelves, 607, in simple 
flat pelves, 608; in vertex presentation, 

501-514. 

Mechanism, of post-partum hemorrhage, 634, 
635; of submucous or muscular rup- 
ture of the pelvic floor. 655. 

Meckel's diverticulum, persistent, 278. 

Meconium, first appearance of, 85; of newly 
born, 847; pathological discharge of, 

79- 

Medullary, folds, 54, 55, 61; cords, 55; 
grooves, 55, ridges, 55; plate, 54. 

Melancholia, following rape, 35; in preg- 
nancy, 120; melancholia, mania, and 
dementia, gestational, 375-377; element i 
of sepsis in, s^3- 

Melena, or gastro-intestinal hemorrhage of 
newly born, 915. 

Membranes, anomalies of, cause of dysto- 
cia, 662; artificial rupture of, 955, 
961, indications for, 955, in second 
stage of labor, 532, technique of, 956; 
at term, 65 ; circular detachment of, 
961; definition of, 61; delivery of, 
543, 1091-1095; dystocia from ad- 
herent, 662; examination of, 545; \ 
obturator, 448; origin of, 61; retention 
of, 630-632; rupture of. in Cassarean 
section, 1086, in labor, 485, in placenta 
praevia, 236; synovial, pelvic, changes \ 
in, in pregnancy, 117; treatment of 
intact, in internal podalic version, 
1000. in shoulder presentation, 1003. 

Meningitis, cerebrospinal, of fetus, 289; ! 
diagnosis of, from eclampsia, 349; in 
labor, 727. 

Meningocele, 275, 897. 

Menopause, 26: anatomical changes after, 
27; anomalies of, 26; average age at, 
26; care during, 41; dangers of, exag- 
gerated, 27; phenomena of, 27. 



Menorrhagia from natural defects, 25; in 
incarceration of uterus, 310. 

Menses, 20; retained, from natural defects, 
25; suppression of, in ectopic gesta- 
tion, 410, 411. 

Menstrual blood, color of, 24; composition 
of, 24; odor of, 24; prejudice as to 
deleterious effects of, 25; reaction of, 24. 

Menstrual cycle, 23, stages of, 23; decidua, 
21; flux, 20; wave flow, 20. 

Menstruation, abnormal age for, 22; ab- 
normal, in subinvolution, 137; age for 
establishment of, 21; blood lost in, 24; 
and child-bearing, relation between, 25; 
and "heat," relation between, 23; and 
impregnation, relation between, 29; and 
ovariotomy, relation between, 25; and 
ovulation, relation between, 25; and 
pathological hemorrhages, confusion 
between, 124: anomalies of, 25; cessa- 
tion of. as sign of pregnancy, 123, in 
acute affections, 124, in chronic diseases, 
124, from emotion, 124, from exposure, 
124; changes in endometrium during, 2 1 ; 
conditions influencing, 23; definition, 
20; disregard of, in relation to sexual 
functions, 37; duration of, 42; etiology 
of, 25; in infants, 916, 917; in the 
obese, 138; in pregnancy, 23, 124; in 
pregnancy, theories concerning, 23; in- 
fluence of, on health, 25; intermittent, 
24; modifications of, 25; nervous con- 
trol of, 26; periodic, 24; persistence of, 
cause of ante-partum hemorrhage, 402; 
phenomena of, 20; phenomena, general, 
20, local, 21, precocious, 22, 916, 917; 
profuse, in uterine tumors, 137; pro- 
longed, 26; relation of, to ovulation, 
25; suppression of, 25; suspension of, 
during pregnancy, 23; symptoms of, 
20; synonyms of, 20; temporary, 24; 
theories concerning, 25; time of occur- 
rence, 21; variations in degree of, 24; 
vicarious, 25. 

Mensuration in pelvic deformity, 713, 
714. 

Mento-posterior positions, persistent, 603- 
607, cranioclasis in, 1020, forceps in, 
1076, 1077; podalic version in, 993, 
posture in, 946. 

Mercurial ointment, in phlegmasia alba 
dolens, 804; in puerperal infection, 818. 

Mercurialism, effect of, on fetus, 293; in 
pregnancy, 293. 

Mercuric bichloride, as antiseptic, 157; 
effect of, on spermatozoa, 28. 

Mercury in infantile syphilis, 877. 

Mesentery, malignant growths of, diagnosis 
of, from pregnancy, 140. 

Mesoderm, 53, 54, 56, 57, 58, 60, 61, 63, 
64, 65, 68. 

Metalloids, effects of, on fetus, 293. 

Metastases, in deciduoma malignum, 208; 
puerperal, 806; in septicemia, 809. 

Meteorism in malignant peritonitis, 801; in 
sapremia, 806. 

Metritis, chronic, cause of fetal death, 303; 
diagnosis of, from pregnancy, 137; in 
pregnane}', 313; puerperal, 794, 795. 

Metrophlebitis, puerperal, 802, 803. 

Metrorrhagia, following coitus interruptus, 
40; in deciduoma malignum, 207; of 






INDEX. 



1133 



labor, 730; of pregnancy, 41S-420; 
puerperal, 761. 

Microcephalus, 272. 

Micro-organisms, in feces of newly born, 847 ; 
in human milk, 855 ; in puerperal infec- 
tion, 153; in secretions of healthy 
women, 828; in vagina of pregnancy, 
152, 153; in vulval secretions, 153; 
pathogenic, in vagina, 152, 153. 

Migration of ovum, 18, 23. 

Milk, causes of poor, 854; cows', 855; changes 
in, during puerperium, 743-747; com- 
parative average composition of human 
and cows', 855; composition of average 
normal human, 854; condensed, com- 
ponents and reaction of, 861; deficient 
secretion of, 826; diet in toxemia of 
pregnancy, 336; ; effect of diet on, 745, 
854; establishment of secretion of, 853; 
excessive secretion of, 826, 827 ; 
formulae for the home modifica- 
tion of, 857; general directions for 
the modification and sterilization of, 
858-860; human, description of, 744- 
747, 855, modifications of, 745, spon- 
taneous coagulation of, 744, 745 ; in 
breasts of newly born, 918; in pre- 
maturity, 869; in threatened eclampsia, 
351; -leg, 803; methods of increasing 
human, 745, 854; micro-organisms in 
human, 855; fever, 812; modifications 
of, 855, 860; prevention of bacteria 
in, 855; secretion, anomalies of, in 
puerperium, 826, 827, in newly born, 
850, in pregnancy, 118, qualitative 
anomalies of, 827; "uterine," 78; 
variations in human, 854. 

Mineral acids, poisoning of fetus by, 293. 

Mineral waters in constipation of preg- 
nancy, 366. 

Minot's definition of chorion, 68. 

Miscarriage, 385-404. 

Missed abortion, 415; labor, 415. 

Modification of milk, 855-S60; apparatus 
for, 859, 860; formulas for the home, 
857; general directions for the, 858-860. 

Molar pregnancy, 208. 

Mole, blood, 388; "mola" carnosa, 205; cys- 
tic, 208; flesh, 388; hydatidiform, 208- 
211; placental, 208; mola sanguinea, 
205; tubal, 407; uterine, 7,88; vesicular, 
208. 

Monstrosities of fetus, 259-285; abrachius, 
278; acardiacus, 28 1; acephalus, 2 82; 
acrania, 280; acromegaly, 272; agen- 
osoma, 279; agnathia, 280; amelus, 
278; amorphus, 282; amphischistoi, 
283; anadidyma, 282; anakatadidyma, 
282; anencephalus, 280; anomalies 
of cleavage, 276; anomalies of de- 
fect, 272-278; aprosopus, 2S0; apus, 
279; aspalosoma, 279; asymmetrical 
double, 283-285; brain monstrosity, 
279, 280; cebocephalus, 281; celocor- 
mus, 279; celosoma, 279; celothorus, 
279; classification of, 259; congenital 
fissures of palatine arch, 272, 273; 
congenital umbilical hernia, 273; cran- 
iopagus, 282; craniopagus parasiti- 
cus, 284; cyclopia, 280; cyclocepha- 
lus, 281; cyllosoma, 279; deradelphus, 
283, tetrabrachius, 283, tribrachius, 



2S3; derothoracopagus, 283; descrip- 
tion of, 2 60-2 85 ; dicephalus di- 
brachius, 2 S3, dipus, 283, tetrapus, 
283, tripus, 283; dicephalus para- 
siticus, 284; double, 281-285, as causes 
of dystocia, 597-599; dwarfs, 272; 
ectromelus, 278, 279; ectroprosopus, 
280; edocephalus, 280; embryotomy in, 
972; encephalocele, 280; endocyma, 
284; epischistoi, 282, 283; essential, 
278-285; ethmocephalus, 281; etymo- 
logical key to, 260; evisceration in, 1030; 
exencephalus, 280; exstrophy or extro- 
version of bladder, 272; face, 280, 281; 
fetal inclusion, 285; general inversion, 
260; general principles in delivery of 
all, 599; giantism, 271, 272; hare-lip, 
272; hemibrachius, 278; hemicephalus, 
280; hemimelus, 278; hemipagus, 283; 
hemipus, 279; hemiterata, 271-278; 
heteralius, 284; heterotypus, 283; hy- 
perencephalus, 280; hyposchistoi, 283; 
hypospadias, 273; iniencephalus, 280; 
ischiopagus, 282; ischiopagus parasiti- 
cus, 284; janiceps, 283, asymmetrus, 
283, symmetrus, 283; katadidyma, 
282; lecanopagus, 282; macrosomia, 
271, 272; major, 277-284; microbra- 
chius, 278; microcephalus, 272; micro- 
melus, 278; micropus, 279; micro- 
somia, 272; monocephalus, 283; mono- 
pygus, 282; multiple, 285; nanosomia, 
271; notencephalus, 280; omphalosites, 
281, 282; otocephalus, 280; paracepha- 
lus, 280; paraprosopus, 280; parasites, 
283-285; perobrachius, 279; peromelus, 
279; peropus, 279; phocomelus, 278; 
pleurosoma, 279; podencephalus, 280; 
polygnathus, 284; polymelus parasiti- 
cus, 284; proencephalus, 280; prosopo- 
thoracopagus, 283; pseudencephalus, 
280; pyogopagus, 282; rachipagus, 283; 
rhinocephalus, 281; sacro-coccygeal tu- 
mors, 284; schistoprosopus, 280; schis- 
tosoma, 279; schistothorus, 279; sin- 
gle, including anomalous individuals, 
260; somatopagus, 282; sphenocephalus, 
281; splanchnic inversion, 260; sterno- 
pagus, 283; stomocephalus, 280; sy- 
melus, 279; symmetrical double, 282, 
283; sympygus, 282; syncephalus, 283; 
synopsia, 280; synotia, 280, 281; terato- 
cephalus, 279, 280; teratocormus, 278; 
teratoprosopus, 280, 281; teratosoma, 
279; teratothorus, 279; thoracopagus, 
283; thoracopagus parasiticus, 284; tra- 
cheo-oesophageal fissure, 273; tricepha- 
lus, 285; triocephalus, 280; trunk, 279; 
twins, homologous, normal, 281, sepa- 
rate, 281; united twins, 282; uterus 
septus, 274; vagina septa, 274; vices 
in minute structure of organs and 
tissues, 278; vices of conformation, 
276, 278; xiphopagus, 283. 

Montgomery's glands, prominence of, in 
pregnancy, 118. 

Morbidity in the puerperium, 770-825. 

Morning sickness, in pregnancy, 118. 

Morphinism, effect of, on fetus, 293, 294; 
in pregnancy, 293, 294. 

Mortality, in abortion, 379; in accidental 
hemorrhage, 241, 242; in accouche- 



1134 



INDEX. 



ment force, 1034; in asphyxia of newly I 
born, 924; in brow presentation, 558; 
in congenital hydrocephalus, 618; in 
convulsive disorders of newly born, 
924; in eclampsia, 349. 35°. 352, 354, 
355; in ectopic gestation, 412 ; in elderly 
primiparae, 725; in face presentation, 
568; in gestational chorea, 378; in in- 
fants in the first year of life, 865 ; in in- 
fantile syphilis, 876; in insanity of the 
puerperium, 837 ; in inversion of the uter- 
us, 648; in kyphotic pelvis, 704; in mel- 
ena, 916; in menopause, 27; in miscar- 
riage, 397; in Naegele's pelvis, 683; in 
osteomalacia, 695; in pelvic presenta- 
tion, 587 ; in pelvic tumor, 696 ; in persis- 
tent occipito-posterior positions, 599; in 
persistent mentoposterior positions, 605 ; 
in penetrating wounds of the gravid 
uterus, 417; in pregnancy after ventro- 
fixation and ventrosuspension, 657; in 
prolapse of umbilical cord, 577; in rup- 
ture of uterus, 645; in typhoid fever 
in pregnancy, 379; in labor with vagi- 
nal obstruction, 669; inversion, 1004; 
maternal, of elderly primiparae, 725; 
maternal, in embryotomy, ion ; mater- 
nal, in placenta prsevia, 229-231; of 
newly born, 865, 914; of newlv born in 
New York, 865. 

Morula, 51. 

Mother's outfit, 517. 

Motion of pelvic joints, exaggerated, 697. 

Moulding, in labor, 492; of fetal head, 464, 
in vertex presentation, 503, 504, 505, I 

509. 5*3- 
Mouth, formation of, 57; of newly born 

child, cleansing of, 538; origin of, sto- 

modeal portion of, 61. 
Movements of fetus, 130. 
Mucosa, uterine, characteristics of, 46 ; 

normal thickness of, 46; thickness of, 

in pregnancy, 46. 
Muller's, manoeuvre in pelvic deformity, 

723; method of engaging fetal head, 

188; test in pelvic deformity, 618. 
Mullerian duct, formation of, 60. 
Multigravida, 43; description of, 141, 142. 
Multipara, 42; definition, 27. 
Multiple abscesses, in newly born, 911. 
Multiple birth, 610-614. 
Multiple pregnancy, course of labor in, 610; 

diagnosis of, 147; etiology of, 144; ' 

hemorrhage of, 612; membranes and 

placenta in, 145, 146; mummification j 

of fetus in, 147; size of children in, 147; 

treatment of, 610-613. 
Multiple presentation, 613, 614. 
Mummification of fetus, 305. 
Murmur, cardiac, in pregnancy, 119, funic, 

133, 134; umbilical, in pregnancy, 133; 

uterine, in pregnancy, 127, 128. 
Muscles, action of abdominal, in labor, 478; 

changes of, in pregnant uterus, 106, 107 ; 

during puerperium, 736; formation of, 

57; origin of, 58, 61; pelvic, 443. 
Myelitis, chronic, complicating labor, 727; 

puerperal, 837. 
Myocarditis in pregnancy, 369. 
Myoma, uterine, cause of dystocia, 659, 660; 

Cassarean section in, 661; diagnosis of, 

660; diagnosis of, from pregnancy, 137; 



effect of pregnancy on uterine, 660 ; prog- 
nosis of, 660; treatment of, 660. 

Myopia, 277. 

Myotome, 57, 58, 61, 65. 

Myxoma chorii multiplex, 208-211. 

Myxoma fibrosum, 211; of placenta, 252. 



N. 

Naegele's, pelvis, 680-683, difference be- 
tween right and left external obliques 
diameter of, 171; forceps, 1056; rule 
for calculating date of confinement, 
150. 

Nsevi, fetal, 297. 

Nagel on the embryo, 65. 

Nails, development of, 84; origin of, 61. 

Nanosomia, 271. 

Nausea in pregnancy, 118, 336; in hydatidi 
form mole, 210; in phlegmasia alba 
dolens, 803. 

Navel, changes in, in pregnancy, 122. 

Navel string, 71. 

Neck, deformities of, 272, 273; formation 
of, 84; structures derived from, earliest 
in development, 53. 

Necrophilia, 31, 36; penalty for, 36. 

Neoplasms, fetal, 301; vesical, in preg- 
nancy, 361. 

Nephritis, in pregnancy, 324, 325, 328, 345, 
347; fetal, 296; indication for preven- 
tion of reproduction in, 39; of newly 
born, 875. 

Nerve, optic, development of, 56. 

Nerves, changes of uterine, in pregnancy, 
in, 112; origin of, 61; pelvic, 450; 
sensory, origin of, 55; sympathetic, 
origin of, 55. 

Nerve-trunks, injuries of, at birth, 890-893. 

Nervous system, diseases of, in pregnancy, 
375-37 8 . in puerperium, 835-837; dis- 
turbances of, in pregnancy, 119; during 
puerperium, 737; origin of, 61; troubles 
of, in menopause, 41'. 

Neural tube, 54, 55. 

Neuralgia, in hydramnios, 217; of legs, in 
pregnancy, 117. 

Neuralgias, gestational, 378. 

Neuritis, puerperal, 835, 836; septic, in 
puerperium, 808. 

Neuroses, following coitus interruptus, 40; 
following interrupted pregnancy, 394; 
in pregnancy, 378. 

Neurotic conditions, fever from, in puer- 
perium, 810, 812. 

Neurotic mother, offspring of, 875. 

New growths during pregnancy, 429; of 
pelvis, 695, 696. 

Newly born child, 845-925; acute infec- 
tious diseases of, 873; amount of milk 
at a feeding for, 858, 859; anasarca of, 
875, 905; aphthae of, 913; artificial 
feeding of, 854, 855; ascites of, 875; 
asphyxia of, 878-889; atelectasis of, 
904, 905; bathing of, 851; Bednar's 
disease of, 919; bladder and bowels 
of, 861; blood of, 849; breasts of, 850; 
Buhl's disease of, 917; cachexia of, 
923, 924, cancrum oris of, 909; care 
and posture of, in bed, 541; care of, 
538, 541, 542; changes in circulation in, 



INDEX. 



1135 



846; chronic infectious diseases of, 874, 
875; clothing of, 852; colic of, 919; con- 
stipation of, 921; convulsions of, 923; 
cutaneous sepsis of, 910-912; cyanosis 
of, 881, 882; cystic elephantiasis of, 
875; dermoid cysts of, 919; diagram 
snowing mortality of, 865; diarrhoea 
of, 920; digestion of, 848; diphtheria 
of, 874; diseases due to bacteria 
and fungi of, 906-913; diseases due to 
fungi of, 913; diseases incident to 
change of environment of, 903-906; 
diseases of unknown nature of, 914-919 ; 
diuretics for, 925; dressing the, 852; 
ductus arteriosus of, 846; ecthyma of, 
911; endocarditis of, 875; effect of 
albuminuria on, 875, of alcoholism on, 
875, of cancerous cachexia on, 875, of 
chronic metal poisoning of mother on, 
875, of diabetes on, 875, of eclampsia 
on, 875, of lead poisoning on, 875, of 
nicotinism on, 875; environment of, 
862; epidemic hemoglobinuria of, 917; 
erysipelas of, 912; establishment of 
respiration in, 541, 845, 846; eyes 
of, 538; failure of circulation of, 905; 
failure of digestion and assimilation 
of, 905; fatty degeneration in, 917; 
feces of, 847; feeding of, 852-861; 
first care of, 851; foramen ovale of, 
846; gain in weight of, 850; gan- 
grenous stomatitis of, 909 ; gastro- 
enteritis of, 910; gastro-intestinal sepsis 
of, 909, 910; general conditions of, 
S75; general phenomena of, 845-851; 
general post-partum conditions of, 
918-925; head of, 851; heart of, 849; 
hemoglobin of, 849 ; hemorrhagic dia- 
thesis of, 914; hemorrhages from 
genitals of female, 916; hemorrhages 
in general of, 914; hematuria of, 916; 
hydrocephalus of, 876; hygiene and 
management of, 851-862; ichthyosis 
of, 875 ; icterus of, 918, length of, 
469; loss of weight of, 850; immunity 
to smallpox of, 873; inanition fever 
of, 906; inanition of, 905; influenza 
of, 874; intestinal obstruction of, 922; 
jaundice of, 918; laxatives for, 925; 
liver of, 849; local remedies for, 925; 
malaria of, 874; malformations and 
monstrosities, of, 873; marasmus of, 
905; mastitis of, 918; maternal nurs- 
ing of, 852-854; measles of, 873; 
meconium of, 847; medication of, 925; 
melena or gastro-intestinal hemorrhage 
of, 915; menstruation in, 916; milk in 
breasts of, 918; miscellaneous hemor- 
rhages of, 916; mortality of, 914; 
mouth of, 538; multiple abscesses 
in, 911; nephritis of, 875, 876; noma 
of, 909 ; number of stools daily of, 847 ; 
nursery for, 861; nursing of, 852,853; j 
obliteration of bile-ducts in the, 875; 
oedema of, 905; omphalorrhagia of, 
915; open air for, 861; ophthalmia of, 
898-902; parotitis of, 909; patented 
or proprietary foods for, 860; patho- 
logical feces of, 84*7 ; pathology of, 
865-925; \ peritonitis of, 875; peri- 
umbilical pemphigus of, 910, 911; 
physiology of the, 845-862; pneu- 



monia in the, 874; post-mortem ob- 
servations of, 851; powders suitable 
for, 852; prevention of ophthalmia in, 
542; primary asphyxia of, 903; pulse 
of, 847; purpura hemorrhagica of, 
916; ranula of, 919; retropharyngeal 
abscess of, 910; rheumatism of, 874; 
rickets of, 875; "run round" of, 911; 
scarlatina of, 873; scleroma of, 917; 
sedatives for, 925; sepsis of, 874, 908; 
septic coryza of, 908, 909; septic infec- 
tion of, 906-908; septic pemphigus of, 
910; septic pneumonia of, 909; shape 
of head of, 851; signs of normal nutri- 
tion in, 850; simple elephantiasis of, 
875; sleep of, 861; soap suitable for, 
852; stenosis of the pylorus of, 875; 
stimulants for, 925; stomachics for, 925 ; 
sex of, 850; stools of, 847, 848; um- 
bilical cord of, 846; sublingual cysts 
of, 919; sudden death of, 924; sutures 
and fontanelles of, 851; syphilis of, 
876-878; temperature of, 847; tetanus 
of, 912; thrush of, 913; tuberculosis of, 
874, 875; ulceration of hard palate of, 
919; ulcerous stomatitis of, 909; um- 
bilical stump and ring of, 846; urine of, 
848; variola of, 873; vesicular or fol- 
licular stomatitis of, 913; vomiting of, 
919; weight of, 850; Winckel's disease 
of. 917. 

Nicotinism, effect of, on fetus, 294, on newly 
born, 875; in pregnancy, 294. 

Nipple, anatomical anomalies of, 825, 826; 
care of, in pregnancy, 194; care of 
rubber, S59; care of, in puerperium, 
752; changes in, in pregnancy, 118; 
congenital absence of, 825; fissured, 
826, treatment, 826; flat and inverted, 
825; in puerperium, 827, 828; sore, 
813, cause of fever in puerperium, 812. 

Nipple, eczema of, in pregnancy, 324. 

Nipple-shield, 826. 

Noma of the newly born, 909. 

Non-impregnation, 39. 

Nostrils, origin of, 61. 

Notochord, 56, 57. 

Nucleus, egg, 44; segmentation, 44, 50, 51; 
sperm, 44. 

Nullipara, 43; definition of, 27. 

Numbness of legs in pregnancy, 117. 

Nurse, obstetric, 522, asepsis of, 816; wet, 
854- 

Nursery, 861. 

Nursing, after Caesarean section, 1088; 
length of period of, 853 ; of newly born, 
maternal, 852-854; proper intervals 
between, 853. 

Nutrition, and sex, relation between, 87; in 
newly born, signs of normal, 850. 

Nymphomania, 36. 

0. 

Obesity, cause of interrupted pregnancy, 

391; in menopause, 27; menstruation 

in, 138. 
Oblique diameter of pelvic cavity, 433; of 

pelvis, 431; of pelvic outlet, 434. 
Oblique, right and left external, 170, 171. 
Obliquely deformed or contracted pelvis, 

680-683. 



1136 



IXDEX. 



Obliquely ovate pelvis, 680-683. 

Obliquity, Naegele's, 503; Solayres', 503. 

Oblong pelvis, 693. 

Oblong rostrated pelvis, 693. 

Obstetric, bag, 517, 518; case, use of , at bed- 
side, 520; examination, 525-530; nurse, 
522; outfit, 516-523. 

Obstetric surgery, 927—1103; accouchement 
force, 1034; amputation of extrem- 
ities, 103 1 ; anesthesia as an aid in diag- 
nosis, 935; anesthesia in, 935, 936; 
artificial rupture of membranes, 955, 
956; blunt hook in, 1081; Caesarean sec- 
tion, 1082-1088, in the dead and dying, 
1090; cephalotomy, 1025; cephalotripsy, 
102 1, 1025; celiotomy for ectopic gesta- 
tion, 1090, 109 1, for sepsis of the uterus, 
1098, in rupture of uterus. 1097; cer- 
vical lacerations. 1098; cleidotomy, 103 1, 
1032; ccelio-hysterectomy, 1089. 1090; 
correction of faulty posture, malposi- 
tions, and malpresentations, 980-983; 
cranioclasis, craniotraction, 1016-1020; 
craniotomy, 1024, 1025; crochet in, 
1082; curettage, 1096; decapitation, 
102 5-1030: delivery of the placenta 
and membranes, 1091-1097; digital ex- 
ploration of uterus, 948; douche, 193, 
194, 547, 628, 949, 961, 1103; embry- 
otomy in general, 1010, 1011; entero- 
clysis, 931; extraction of after-coming 
head, 1044-1054; extraction of fetus 
mutilated by embryotomy, 1082; ex- 
enteration or evisceration, 1030; fillet, 
983; forceps, 1054-1078; hypodermo- 
clysis, 932, 933; incisions of the cervix, 
vagina, and vulva, 975-980; induction 
of abortion and premature labor, 
966-968; intra-arterial infusion, 930; 
intrauterine irrigation, 950-952; intra- 
venous infusion, 930, 932; introduction 
to, 927; instruments and dressings in, 
928, 929; instrumental dilatation of the 
cervix, 969, 974; intra-uterine packer in, 
954 ; manual and instrumental dilatation 
of vagina and vulva, 974, 975; manual 
dilatation of cervix, 963-969; manual 
removal of placenta, 1094, 1095; oper- 
ations for delivery, 1032-1097, for the 
correction of injuries, 1097, preparatory 
to delivery, 955-1033; passing the cath- 
eter, 955; pelvic-floor lacerations, repair 
of, 1099-1103; perforation of skull, 
1012, 1013; pelviotomy, 1005; Porro- 
Cassarean section, 1089; posture in 
obstetrics, 936-947; preparation of 
patient, 928; preparation of saline solu- 
tion for injections, 929; rachidotomy 
in, 1015; rectal infusion, 929, 930; 
repair of injuries to cervix, vagina, 
rectum, perineum, and clitoris, 1098- 
1103; reposition of small parts, 984- 
987; shoulder extraction in head-first 
cases, 1037, 1038; sling or soft fillet 
in, 1078; spondylotomy, 1033; supa- 
vaginal hysterectomy, 1089; symphy- 
seotomy, 1008-1010; uterine tampon, 
953-955; vaginal irrigation, 949, 950; 
vaginal lacerations, 1098, 1099; vaginal 
Caesarean section, 1088, 1089; vaginal 
tampon, 952, 953; version, 987-1005; 
vectis, 983 ; vulval douche, 949. 



! Obstetrical paralysis, 377, 378, 836, 837. 
Obstructed labor, 623. 
Obturator internus muscle, 447; membrane, 

448. 
Occipital protuberance, fetal, 459. 
I Occipito-anterior position, left, mechanism 

of, 501—508; right, mechanism of, 509. 
I Occipito-posterior positions, forceps in, 
1072, 1073; internal podalic version 
in, 997 ; persistent, 597-603 ; per- 
sistent, definition, 597, diagnosis, 599, 
etiology, 597, frequency, 597, mechan- 
ism, 598, external manual rotation 
in, 601, internal manual rotation in, 

601, prognosis, 599, treatment, 600- 
603, treatment, in high cases, 601, 

602, treatment in low cases, 602, 
treatment in medium cases, 602, treat- 
ment, operative, 600-603, cranioclasis 
in, 1020; treatment, prophylactic, 600, 
podalic version in, 993, posture in, 
946, right, conversion into face pres- 
entation. 511. 

Occiput, fetal, 459; posterior rotation and 
birth of, over the perineum, 508-511; 
posterior rotation of, and impaction, 
510, 511; rotation of, in vertex pres- 
entation, 506, 508, 509. 

Ocular paralyses during the puerperium, 

837- 

(Edema, general fetal, 301, 303, general fetal, 
in twin monstrosities, 303; genital, and 
breech extraction, 1039; i n pregnancy, 
133; neonatorum, 905; of legs, in preg- 
nancy, 117; of placenta, 243; of vulva 
and vagina, a cause of dvstocia, 670, 
671. 

Olfactory organs, origin of, 61. 

Oligohydramnios , 215. 

Oligolactia, 826. 

Oligospermism, 29. 

Olliver's axis-traction forceps, 1074. 

Omental adhesions, prevention of, in 
Caesarean section, 1087. 

Omentum, malignant growths of, diagnosis 
from pregnane}', 140. 

Omphalomesenteric veins, origin of, 78. 

Omphalorrhagia of newly born, 915; prog- 
nosis, treatment, 915. 

Oophoritis, during puerperium, 797; fol- 
lowing coitus interruptus, 40. 

Operations, choice between chloroform and 
ether for, 935; for correction of in- 
juries, 1 097-1 103; for delivery, 1032- 
1097; in pelvic-floor lacerations, 1100- 
1103; in pregnancy, 417; in rupture 
of uterus, 646, 647; preparations for, 
928, 929; preparatory to delivery, 955- 
1032. 

Ophthalmia neonatorum, 898-902; preven- 
tion of, 542. 

Opiates in colic of newly born, 920; in 
malignant peritonitis, 801; in puerperal 
parametritis, 796. 799; in puerperal 
perimetritis, 799; in psychoses of preg- 
nancy, 377; in rigidity of the os, 665. 

Optic cup, formation of, 56. 

Oral sepsis in pregnancy, 364. 

Organisms (see Bacteria). 

Organogenesis. 256. 

Organs, embryology of, 54; enlarged ab- 
dominal, diagnosis of, from pregnancy, 



INDEX. 



1137 



140; formation of primitive, 54; genital, 
origin of, 61; of taste, origin of, 61; 
olfactory, origin of, 61; tactile, origin 
of, 61; urinary, origin of, 61. 

Orgasm, 27. 

Orthotherapy in puerperal sepsis, 817, 818. 

Os, acquired rigidity of, a cause of dystocia, 
664; congenital atresia and stenosis of, 
a cause of dystocia, 663, 664; con- 
stitutional or anatomical rigidity of, a 
cause of dystocia, 664, 665; inflam- 
matory rigidity of, 664; internal and 
external, functional or spastic rigidity 
of. a cause of dystocia, 663; internal, 
dilatation of, during labor, 483 ; manual 
and instrumental dilatation of, 958; 
occlusion of the external, a cause of 
dystocia, 667; organic rigidity of, a 
cause of dystocia, 663, 664, 665. 

Osiander's sign in pregnancy, 129. 

Ossa innominata, 423. 

Osseous system, diseases of the, in fetal 
syphilis, 291; in pregnancy, 383, 384. 

Ossification, errors in, 278; placental, 250. 

Osteochondritis, syphilitic, of newly born, 
877. 

Osteomalacia, 692-695; in animals, 693; in 
pregnancy, 369, 370. 

Osteophytes, puerperal, in pregnancy, 122. 

Osteosarcomata, pelvic, 696. 

Outlet, pelvic, anatomical, boundaries of, 
433, antero-posterior diameter of, 172; 
axis of bony pelvic, 437 ; axis of parturi- 
ent, 437 ; measurement of circumference 
of pelvic, 434; obstetric, boundaries of, 
433; pelvic, description of, 433; plane of 
the parturient, 436; transverse diameter 
of, in pregnancy, 171, 172. 

Ova, maturation of, 25; number in ovary 
of new-born child, 43; origin of, 17, 
60; primordial, 43; spontaneous fer- 
tilization of, 87. 

Ovarian, cyst, diagnosis of, from hydram- 
nios, 216, 217; extract in osteomalacia, 
693; pregnancy, 404, 405, external, 
408, pathology of, 408; tumors, a cause 
of dystocia, 661, in pregnancy. 660. 

Ovaries, accessory, 319; changes in before 
ovulation, 25; malposition of, 319; 
origin of, 61; rudimentary, 319; super- 
numerary, 319. (See Graafian follicles.) 

Ovariotomy and menstruation, relation be- 
tween, 25; in osteomalacia, 693, 695. 

Ovate pelvis, 680-683. 

Ovoid, fetal, 471. 

Ovular abortion, 394. 

Ovulation, 17; and menstruation, relation 
between, 25; a periodic process, 17; 
nervous control of, 26. 

Ovum, 43 ; characteristics of, in the several 
lunar months, 82; cystic disease of, 208; 
definition of, 77; description of prim- 
ordial, 43; deutoplasm of , 78; diagnosis 
of. from blood-clot, 397; diseases of, 
258; earliest human, 65, description of, 
82; external migration of , 18; fecunda- 
tion of, with double yolk, 144; fertili- 
zation of, 29; in abortion, 387; in 
first month, 82, 83; in second month, 
84; in third month, 84; maturation of, 
44; mature, 43; metabolism of, 77; mi- 
gration of, 18, 23; morula of, 51; 
72 



nutrition, of, 77, 78; of fourth week, 
characteristics of, 83 ; point of fecunda- 
tion of, 29; primordial, 43; primitive 
streak of, 53; pronucleus of, 44; 
Reichert's, 68; segmentation of, 50; 
segmentation-nucleus of, 51; size of 
mature, 43; Spee's, 53; zona pellucida 

of, 43- 5 1 - 

Oxygen, fetal absorption of, 78; in dyspnea 
of pregnancy, 374; in eclampsia, 354; 
in puerperal infection, 817; in puerperal 
syncope and shock, 840; in puerperal 
thrombosis and embolism, 834. 

Oxytocic action of forceps, 1057. 

Oxytocics, 391, 392. 



P. 

Packer, mechanical, for surgical dressing, 
954- 

Pain, false labor, 481, distinguished from 
true, 483 ; in accidental hemorrhage, 
240; in deciduoma malignum, 206; in 
ectopic gestation, 410, 411, 412; in 
hydatidiform mole, 211 ; in legs, in preg- 
nancy. 117; in puerperal infection, 821, 
822; in rupture of fetal cyst, 409; in 
uterine inertia, 606; labor, 479, 480, 
481; over-strong labor, posture in, 944; 
slight, in precipitate labor, 624. 

Pajot's law of accommodation, 471; man- 
oeuvre, 1056. 

Palate, origin of, 84; ulceration of the 
hard, in newly born, 919. 

Palatine arch, congenital fissures of, 272, 273. 

Palpation in pelvic deformity, 713; of 
uterus, in pregnancy, 124. 

Palper-mensurateur, 188. 

Palpitation in pregnancy, 370; treatment 

of, 37°- 

Pancreas, formation of, 57; origin of, 61. 

Para, table of, 390. 

Paralysis, auditory, in puerperium, 837; 
facial (see Facial Paralysis) ; gesta- 
tional, 377, 378; in puerperal throm- 
bosis and embolism, 834; obstetrical, 
377, 836, 837; ocular, in puerperium, 
807; of arm at birth, 891, 892; of pla- 
cental site, 637, cause of inversion of 
uterus, 647; puerperal, 836, 837; trau- 
matic, puerperal, 836, definition, eti- 
ology, 836, prognosis, symptoms, 835, 
837; treatment, 800. 

Parametria, secondary implication of, 823. 

Parametritis, diagnosis of, from perime- 
tritis, 799; malignant erysipelas, 795, 
in puerperium, 795, 796; coexistent 
with perimetritis, 799; treatment of, 
796. 

Paraplegia, puerperal, 837. 

Parental characteristics, in pelvic deform- 
ity, 715. 

Parents, variation of weight of newly born 
due to, 850. 

Parietal, presentation, anterior, 571, poste- 
rior, 572; protuberances, fetal, 459. 

Parity, in relation to interrupted preg- 
nancy, 390. 

Parotitis, fetal, 289; in newly born, 909; 
puerperal, 804. 

Parthenogenesis, 87. 



1138 



INDEX. 



Parturient canal, as a whole, 455-458; axis 
of, 458; definition, 450; diameters of the, 
496; formation of, 450; intrapelvic por- 
tion of, 455 ; pelvic portion of, 455 ; shape 
of, 496; suprapelvic portion of, 455. 

Parturient outlet, axis of, 437; plane of, 436. 

Parturient tract, axis of, 437. 

Parturiometer, 481. 

Parturition. (See Labor). 

Partus conduplicatio corpore, in shoulder 
presentation, 594; immaturus, 385; pre- 
maturus, 385. 

Passages, the 407. 

Pathology, antenatal, 257; embryonal and 
fetal in general, 257; of early human 
embryo, 258; of labor, 551-730; of newly 
born, 865-925, due to interruption of 
pregnancy, 866-872; general consider- 
ations of, 865; of pregnancy, 199-420; of 
puerperium, 761-842. 

Patient, preparation of, for examination 
in pregnancy, 154; for operation, 928. 

Pelvic, angles, definition, 437; application of 
forceps, 1063— 1068; articulations, ano- 
malies of, 769; binder in puerperium, 
755; cavity, arrest of the breech in, 
1042-1044, axis of, 436; cellulitis, puer- 
peral, 795, 796; diameters, comparison 
of different, 438; disease in relation to 
mode of life, 73; floor, central perfora- 
tions of, 1099, lacerations of, 652-657, 
1099-1103; inclination of, 426, defini- 
tion of, 437; inlet, arrest of the breech 
above, 1039, arrest of the breech at, 
1039— 1042, axis of, 437, description of, 
430-433, obstetric plane of, 435, plane 
of, 435 ; joints, diastasis of, cause of dys- 
tocia, 673, exaggerated motion or sepa- 
ration of, 697, functions of, 426, inflam- 
mation of, in pregnancy, 383, relaxa- 
tion of, in pregnancy, 383; outlet, cir- 
cumference of , 434, description of, 433, 
434, measurements of, 434, obstetric 
landmarks of, 434, plane of, 436 ; planes, 
434; presentation, 579-590, forceps in, 
1074, sling in, 1078, 1079, version in, 
1004, Walcher's position in, 716. 

Pelvic deformity, 673-724; abortion in, 
723; artificial abortion in, 715; arti- 
ficial premature labor in, 716; avoid- 
ance of conception in, 715; Caesarean 
section in, 715, 716, 718, 719, 720, 723, 
724; celibacy advisable in, 715; ceph- 
alometry in, 723; cephalotripsy in, 
722; classification and description of 
different varieties of, 675; combined 
methods of treatment in, 722, 723; 
cord prolapse in, 713; cranioclasm in, 
722; definition of , 673; diet in, 716; em- 
bryotomy in, 718, 719, 720, 722, 724; ex- 
pectant method in, 721 ; forceps in, 718, 
720, 721, 722, 724, 725; frequency of, 
673; general conclusions concerning, 
721-723; general diagnosis of, 713; gen- 
eral etiology and development of, 675; 
general symptomatology of, 71 1-7 13; 
high forceps in, 716; indication in abso- 
lute, 723; indications in relative, 723; in- 
duction of premature labor in, 721; in- 
spection in, 713; labor prolonged in, 713; 
laparohysterectomy in, 722; marriage- 
ability of women with, 723 ; mensuration 



in, 713; methods of managing dystocia 
from, 721; Muller's manoeuvre in, 723; 
Miiller's test in, 718; palpation in, 
713; parental characteristics in, 715, 
718; pelvimetry in, 713, 714; pendulous 
abdomen in, 713; perforation in, 722; 
Perret's method in, 723; previous 
history in diagnosis of, 713 ; Prochow- 
nik's diet in, 716-718, 721, 723; prog- 
nosis of, 714; prophylactic treatment in, 
715-718; resume of treatment in, 723, 
724; rupture of the uterus in, 713; 
subjective symptoms, in labor in, 713, 
in pregnancy, 711, 713; summary of 
prophylaxis in, 718; statistics showing 
course of labor in, 720; symphyseotomy 
in, 716, 718, 719, 720, 722, 724; thera- 
peutic abortion in, 721; jtreatment of, 
715-724, after conception has occurred, 
715, after marriage and before concep- 
tion, 715, before marriage, 715, cura- 
tive, 718-720, dependent upon degree 
and kind of contraction, 719, of 
married and pregnant women with, 
723, of married but not pregnant 
women with, 723, of patient in labor 
with, 723, 724, prophylactic, 715-718; 
vaginal Cesarean section in, 722; 
version in, 716, 718, 720, 721, 722, 723; 
Walcher posture in, 722. 

Pelvigraphy, 184. 

Pelvimeter, Baudelocque's, 168; Farabeuf's, 
179; Schultz's, 168; Skutsch's, 179; 
Stein's, 177. 

Pelvimetry, external, 428, 168-173; external 
measurement in, 168; indirect, by 
measuring the sternum, 185; in pelvic 
deformity, 713, 714; in labor, 526; 
internal, 173-183; internal manual, 
181, 182, 183; objects of internal, 173; 
Rontgen, 183. 

Pelviotomy, 1005. 

Pelvis, acanthopelys, 695 ; age in relation to, 
439, 440; alterations of, by high heels, 
38, 39; anatomical, 423; angles of, 
437, 438; ankylotic, 683, 684; anom- 
alies, due to atrophy, caries and 
necrosis of, 696, 697. faulty defective 
development, 676-686, as a result of 
disease of the pelvic bones, 675, 687- 
697, due to disease of superimposed 
parts of the skeleton, 675, 698-708, due 
to disease of the weight-bearing parts 
of the skeleton, 675, 708-711, in junc- 
tion of pelvic bones, 697, 698; artic- 
ulations of, 424; assimilation, 707, 
708; axis of, 436, 437; blood-vessels 
of, 449, 450; bones of, 423; bony, 423; 
definitions of, 423; cavity of, 432, 433, 
cellular tissues of, 448, 449; clinical 
measurement of the, 472; congenital 
predisposition influencing shape of, 
440; contracted, embryotomy in, 1012, 
indication for prevention of reproduc- 
tion, 39, position during labor in, 944; 
cordiform, 693; coxalgic, 708; deep 
palpation of, in pregnancy, 165, 166; 
deformed, general symptomatology 
of, 711,713; depth of, 433; derivation, 
423; description of cavity of, 432, 433; 
description of outlet of, 433; dia- 
phragm of, 445, 446; diastasis of joints 



INDEX. 



1139 



of, in labor, 673; disease of, due to 
abortion, 41, in relation to marriage, 
39; dwarf type, 676; external cir- 
cumference of, 172, measurement of, 
428, 429, 472; external surface of, 427; 
factors influencing size and shape of, 
439; false, 427, 428; female, 439; fetal 
or lying-down or undeveloped, 679, 
680; flat rachitic, 678, 679; forces 
leading to the production of the adult, 
440, 441 ; fractures of, anomalies due 
to, 696, cause of dystocia, 673; func- 
tions of, 443; generally contracted 
flat, non-rachitic, 679; generally equally 
contracted rachitic, 689, 691, 692; 
generally equally enlarged, 684, 685; 
generally symmetrically contracted, 
non-rachitic, 676, 677; glands of, 450; 
inclination of, 437; infantile, 439, 440, 
676; inferior, 429; inferior strait of, 
433; inlet of, 430-432; internal sur- 
face of, 427; inverted, 685; joints of, 
424; justo-major, 684; justo-minor, 
676; juvenile, 439; ligaments of, 448; 
lordosis of, 708; lymphatics of, 450; 
malacosteon, 692; male, 439; mechani- 
cal influences in the formation of, 441 ; 
measurements of the, 472, in obliquely 
contracted, 171, in pregnancy, 168- 
190; muscles of, 443; Naegele's. 680- 
683; narrow, male, funnel-shaped, 679, 
680; nerves of, 450; new growths of, 
695, 6q6; obliquely deformed or con- 
tracted, 680-683; obstetric, 423, 429; 
obstetric landmarks of cavity of, 433; 
obtecta, 702 ; obturator membrane of, ! 
448; of newly-born child, 439, 440;! 
osteomalacic, 692-695; outlet of, 433, 
434; ovate, 680; planes of, 434-436; 
postures which alter shape of, 936- 
939; postures which elevate, 939-944; 
Prague, 698-701; pseudo-osteomalacic, 
689-692; rachitic, 687-692; Robert's, ' 
683, 684; rostrate, 692, 693; scolio- ' 
rachitic, 706; sex in relation to, 639; 
sexual differences in, 639; simple flat, ; 
non-rachitic, 677-679; simple flat, ra- 
chitic, 689; size and shape influenced ; 
by certain factors, 639; soft parts of, 
443; split, 685; spondylolisthetic, 698- 
701; static, 423; superior strait of, 
430; transversely contracted, 683, 684; 
true, 427, 429, 430. 

Pelzer's method of abortion, 960, 961. 

Pemphigus, acutus, neonatorum, 910; peri- 
umbilical, of newly born, 910, 911; 
puerperal, 808. 

Penoyee's forceps, 1056. 

Peptogenic milk powder, components and 
reaction of, 860. 

Peptonuria in pregnancy, 362; in puer- 
perium, 736. 

Percussion, abdominal changes in, in preg- 
nancy, 128. 

Perforation (see Craniotomy), 1013-1016; ', 
in accidental hemorrhage, 242; in after- 
coming head, 10 14; in bregma pre- 
sentation, 1015; in brow presentation, j 
10 15; in congenital hydrocephalus, 619; ! 
in face presentation, 10 15; in pelvic ] 
deformity, 712; in pelvic presentation, 
10 14; in Robert's pelvis, 684; in 



threatened rupture of the uterus, 
645; in tumors causing absolute ob- 
struction to delivery, 659-662 ; in vertex 
presentation, 10 15, indications for, 1013; 
operation of, 1013-1015. 

Periarteritis of umbilical cord, 256. 

Pericarditis, puerperal, 804. 

Pericardium, formation of, 58. 

Perimetritis, 797, 798; puerperal, 798, 799; 
diagnosis of, from parametritis, 799. 

Perimetrium, secondary implication of, 823. 

Perineal lacerations, 1199. 

Perineo-rectal lacerations, 652-657. 

Perineo-vaginal lacerations, 1099. 

Perineum, central perforations of, 1099, 
repair of, 1103; inspection and repair 
of, 542 ; lacerations of, increased by 
manual extraction of shoulder, 540; 
preservation of, during delivery of 
shoulders, 538; protection of, during 
second stage of labor, 532-540. 

Periphlebitis of umbilical cord, 256. 

Peritoneal pregnancy, 404, 405. 

Peritoneum, changes of, in pregnancy, 112. 

Peritonitis, a result of curettage, 819; en- 
cysted, diagnosis of, from pregnancy, 
140; of fetus, 291-295, of newly born, 
875; puerperal, 797-802; puerperal, 
benign forms of, 797, 798, circum- 
scribed, 797, general, 799-802, 803, 
genesis of, 797; puerperal, malignant, 
799-802, diagnosis and prognosis of, 
801, etiology of, 799, symptoms of, 801, 
treatment of, 801, 802. 

Periumbilical pemphigus of newly born, 
910, 911. 

Periuterine inflammation and adhesion dur- 
ing pregnancy, 314. 

Pernicious anaemia, an indication for pre- 
mature delivery, 957, 958, 

Perret's method of cephalometry, 186, in 
pelvic deformity, 723. 

Perspiration during puerperium, 733, 735, 

736- 

Pertussis, fetal, 289. 

Pes equinus, 277; talus, 277; valgus, 277; 
varus, 277. 

Pessary, in retroflexion of gravid uterus, 311. 

Peter's embryo, 47, 65; ovum, descrip- 
tion of, 82. 

Pharynx, origin of, 61. 

Phlebitis, in pregnancy, 256; puerperal, 
cellulitic, 803, 804: puerperal, femoral, 
803, 804; puerperal, para-uterine, 802, 
803; puerperal, septic, 802, 803; puer- 
peral, thrombo-phlebitic, 803; puer- 
peral, uterine, 802, 803. 

Phlegmasia alba dolens, 803, 804; a result 
of curettage, 819. 

"Phobias," in pregnancy, 376. 

Phosphates in liquor amnii, 66. 

Phosphorism in pregnancy, 293. 

Phosphorus-poisoning, effect of, on fetus, 

29.3- 

Phthisis (see Tuberculosis) . 

Physician, asepsis of, in obstetric practice, 
815, 816; family, duties of, 41; prep- 
aration of, for vaginal examination of 
pregnant women, 154. 

Physician's obstetric bag, 517, 518. 

Physiological pregnancy, 42. 

Physiology of newly born, 845-862. 



1140 



INDEX. 



Physometra, after putrefaction of fetus, 
306; diagnosis of, from pregnancy, 136. 

Pigeon-breast, 688. 

Pigmentation, abdominal, in pregnancy, 
129; anomalies of, 278; in pregnancy, 
133, 134, 381; of breasts, in pregnancy, 
118; of genitals, in pregnancy, 91; 
of skin, in pregnancy, 121. 

Pining of pregnancy, 366. 

Pitois's operation of double pubiotomy, 
1005. 

Placenta, 70-71; accidental hemorrhage 
from, 237-243; abscess of, 244; adhe- 
sions of, 248, 249; after expulsion, 71; 
and membranes, delivery of, 1091- 
1097; angioma of, 252; annular, 220; 
anomalies of, 222-225; and diseases of, 
219-252; apoplexy of, 243-246, 389; 
cause of ante-partum hemorrhage of, 
420; atrophy of, 222; battledore, 224; 
bilobed, 223; calculi of, 250; canalized 
fibrin of , 2 49 ; " circular vein of the ,"71; 
circulation, 70-78; circumvallata, 224; 
cotyledons, 71, Crede's method of ex- 
pressing, 543-545, 1091-1094; curling 
arteries of , 70; delivery of, 489, 490, 543, 
in Cassarean section, 1075; degeneration 
of, 248, 250,251; detached, 71; extrac- 
tion of, 1094; dimensions of, 71 ; diseases 
of, 219-252 ; duplex, 222 ; Emanuel's dis- 
ease of, 246; examination of, 544, 545; 
expulsion of, in case of twins, 612; 
fenestrated, 222; fetal surface of, 71; 
formation of, 64, 65; functions of, 70, 
78, 81; hematoma of, 243-246; horse- 
shoe, 222; hyperplastic changes in, 248; 
hypertrophy of, 222; in albuminuria, 
361, 362; in ectopic gestation, 413; in- 
farcts of, 243-246, 248-250; infectious 
granulomata of, 247, 248; inflamma- 
tion of, 246, 247; injuries of, 237-243; 
interstitial hemorrhage of, 243-246; in 
twin pregnancy, 146; lobate, 222; 
location of, 1084; low implantation 
of, 227, a cause of intrapartum hem- 
orrhage, 730; malformation of, in 
placenta prasvia, 227; margin ata, 224; 
maternal surface of, 71; mature, 70, 
71; _ membranacea, 220; multiple 223; 
origin of, 84; ossification of, 250; 
pigment deposits in, 251; polypi of, 
252; prasvia, 225-237, accouchement 
force in, 236, 962, bimanual dilatation 
in, 966, bipolar podalic version in, 994; 
premature detachment of a normally 
situated, 237-243; retention of, 545, 
630-633, in miscarriage, 381; sclerotic 
changes in, 248; secondary alterations 
in, 248-251; separation of, cause of 
ante-partum hemorrhage, 420; site of, 
71; paralysis of, 637; syphilis of, 247, 
248; time for artificial expulsion of, 
1091; thrombosis of, 243; transmission 
of disease by (see Antenatal disease 
of fetus), 285-304, 873-878; tuber- 
culosis of, 247; tumors of, 251; weight 
of, 71, in relation to fetal weight, 222; 
white infarcts of, 249, 250. 

Placentitis, 246, 247; acute septic, 246; 
albuminuric, 247; gonorrhceal, 246; 
interstitial, 247; renal, 247; specific, 
246, 247. 



: Plane, middle, of pelvic cavity, 436; ob- 
stetric, of pelvic inlet, 435; of fetal 
head, 466-468; of fetal trunk, 469; of 
greatest pelvic dimensions, descrip- 
tion of, 436; of parturient outlet, 436; 
of pelvis, 434. 
! Pleurae, formation of, 58. 

Pleuritis, in pregnancy, 372; in puerperium, 
804. 
1 Pleuropneumonia, septic purulent, of the 

newly born, 909. 
I Plumbism, effect of, on fetus, 293; in preg- 
nancy, 293. 

Pneumococcus sepsis, of fetus, 288. 

Pneumonia, aspiration, 897, 898; in fetus, 
288; in newly born, 874; in pregnancy, 
288, 379; septic, of newly born, 909; 
with labor pending, 727. 

" Pocket ruptures " of the vagina, 651, 782. 

Podalic version, 993-1004; combined or bi- 
polar (see Combined bipolar podalic 
version.) 

Poisoning, acute, of fetus, 292, 293; cause 
of fetal death, 304; chronic, in preg- 
nancy, 293, 294; of newly born, 875. 

Poisons, cause of sudden death in preg- 
nancy, 416; elimination of, in eclamp- 
sia, 353, 354; in relation to sper- 
matozoa, 28. 

Poles, fetal, palpation of, 163, 164. 

Polygalactia, 745, 826; treatment, 827. 
1 Polyhydramnios, 215-219. 
! Polymazia, 826. 

1 Polypi after abortion, 399; intracervical, 
cause of antepartum hemorrhage, 420; 
placental, 252; uterine, diagnosis of, 
from inversion of uterus, 647. 

Polyspermism , 29. 

Polyuria in pregnancy, 362. 

Porro-Caesarean section, 1089, 1090; in 
cancer of uterus, 668; in pelvic de- 
formity, 722. 

Porro operation, in obstruction of vagina, 
670; in rupture of the uterus, 1097; 
in shoulder presentation, 597. 

Portio vaginalis, changes in, in pregnancy, 

Posenheim's formula for rectal feeding, 
344- 

Position of fetus, 475-477; definition of, 
475; deep transverse, 608; English, 
French and German classification of 
vertex, 476; fetal, diagnosis of, 161- 168; 
frequency of first vertex, explained, 
476; high transverse, 605-608; left 
vertex, occipito-posterior, persistent, 
597; in simple flat pelves, 605, 608; 
persistent mento-posterior, 603-605; 
relative frequency of, 476; transverse. 
590; transverse, of the head at the 
pelvic outlet, 608, 609. 

Postmortem Cassarean section, 1090. 

Posture in obstetrics, 936. 

Pregnancy, abdominal, ballottement in, 
129, binder in, 193; abnormal, 199; 
abnormal age of, 22, 23; abnormal 
condition in twin, 147; abnormal crav- 
ings in, 119; accidents and injuries in, 
416, 417; acetonuria in, 7,6^', acne in, 
380; acute nephritis during, 357; after 
operations involving the genitals, 416; 
after ventrofixation and ventrosus- 



INDEX. 



1141 



pension, 417; albuminuria in, 120, 325, 1 
344, 361 ; alcoholism in, 293 ; alopecia in, | 
382, 383; amaurosis in, 377; amblyopia ! 
in, 119; amnion in twin, 146; ampullar, ! 
405; anemia in, 120; and abdominal 
tumor, 141; and appendicitis, 141; and 
ascites, 140; and distended bladder, I 
141; and floating kidney, 141; and 
hydrosalpinx, 141; and liver, displaced, 
141; and lactation, relation between, I 
2 5 ; and labor after ventrofixation and 
ventrosuspension, 658-659; and ovarian 
tumor, 138, 139, 141; and pelvic 1 
tumor, 141; and pyosalpinx, 141; and 
spleen, displaced, 141; and tuberculosis, | 
37 2 ~373'' an d tumor of broad ligament, | 
141; and ventral hernia, 141; aneurism 
in, 369, 370; anorexia in, 365; ante- 
flexion of uterus in, 307, 308; antever- 
sion of uterus during, 307, 308; anthrax 
in, 289; apoplexy in, 375; a pre- 
disposing cause of tuberculosis, 372, 
373; appendix removed in, 417; areola, 
secondary in, 118; arsenicism in, 293; 
asthma in, 374; asylum treatment of 
psychoses of, 377; bacteriology of ' 
vagina in, 152, 153; ballottement in, 
133; bathing in, 193; before menstru- 
ation, 25; binder in, 193; blood con- 
dition in, 370; bowels in, 192; Braxton- 
Hicks's sign of, 127; breasts in, 129, 
130, 194; breech presentation, palpation 
in, 166; bronchitis in, 371; cancer in, 
293; cardiac diseases in, 294; care of 
nipples in, 194; cephalalgia in, 379; 
cephalic prominence in, location of, 164, 
165, 166; cephalometry in, 186-190, 
internal instrumental, 188, internal 
manual, 190, Rontgen, 190; cerebral 
disease in, t,6; cervical canal in, 94; 
cervical consistence in, 93; cervical ! 
softening in, 94, 125; cervix in, 93, 
cessation of menstruation in, 123, 124; 
changes in abdomen in, 129, in bladder 
in, 117, in blood in, 120, 195, in breasts 
in, 117, 118, 129, in cervix in, 151, in 
cranial cavity in, 122, in disposition \ 
in, 120, in gait in, 122, in liver in, 119, 
in lower extremities in, 117, in lungs 
in, 119, in lymphatic glands in, 119, 
in navel in, 122, of ovarian artery in, j 
in, in pelvic joints in, 117, in 
pelvic ligaments in, 117, in pelvic 
synovial membranes in, 117, in portio | 
vaginalis in, 151, in rectum in, 117, in 
skin in, 121, in spleen in, 119, in 
symphysis in, 117, in urine in, 120, 121, 
in uterine arteries in, 109, no, in, of 
uterine axis in, 105, 106, of uterine j 
contractility in, 115, in uterine fibrous 
tissue in, 109, in uterine irritability 
in, 115, in uterine ligaments in, 113, 
114; in uterine lymphatics in, 112, in 
uterine musculature in, 106, 107, in 
uterine nerves in, in, 112, in uterine 
peritoneum in, 112, in uterine position 
in, 105, in uterine sensibility in, 114, 
115, in uterine shape in, 103, 104, in 
uterine situation in, 105, in uterine 
size in, 96, 97, 102, 103, in uterine 
volume in, 96, 97, 102, 103, in uterine 
veins in, 109, no, in uterine walls in, | 



113, in uterus in, 95-116, 124-128, in 
vagina in, 128, 129, in vulva in, 128; 
chloasma of, 121; cholera in, 286; 
chorea in, 364; chorion in twin, 146; 
chronic nephritis during, 358; chronic 
poisoning in, 293, 294; chyluria in, 316; 
.cliseometry in, 185, 186; clothing in, 
193; constipation in, 118, 366; corsets 
in, 193; coal-gas inhalations in, effect 
on fetus of, 292; contractions, inter- 
mittent, in, 127; cornual, 414, 415; 
cough, in, 374; cramps of legs in, 117; 
cravings in, 118; cystic vaginitis during, 
322; cystitis in, 359, 360; cystocele 
in, 322, 361; deafness in, 377; death 
of fetus in, 304; decidua, in twin, 145, 
146; definition of, 43; dementia in, 
120; dental caries in, 364; depression, 
mental, in, 194; diabetes in, 294; 
diagnosis, differential, of, 237, from 
chronic metritis, 137, from congestive 
hypertrophy of uterus, 138, from 
cystoma, 138, 139, from distended 
bladder, 138, from distended tubes, 
140, from ectopic gestation, 140, from 
enlarged abdominal organs, 140, from 
encysted peritonitis, 140, from fecal 
accumulation, 138, from fibroma, 137, 
from hematometra, 136, from hema- 
toma, 136, from hydrometra, 136, from 
malignant mesenteric growths, 140, 
from malignant omental growths, 140, 
from myoma, 137, from ovarian tumor, 

138, from pelvic exudations, 139, from 
pelvic hematocele, 139, from physo- 
metra, 136, from pyometra, 136, from 
retroflexion, 139, from retroversion, 

139, from subinvolution, 137, from 
tympanites, 139, from wanderin kidg- 
ney, 140, from wandering spleen, 140; 
diagnosis of fetal position, 1 61-168, of 
fetal presentation, 1 61-169; diagnosis 
of, importance of, 122; diagnosis of, 
134, 141; diarrhoea in, 118, 367; diet 
in, 192; disease of the alimentary 
tract in, 364-367, of the circulatory 
system in, 368-371, of the genital 
organs in, 307, of the nervous system 
in, 375-378, of the osseous system 
in, 383, 384, of the respiratory sys- 
tem in, 371, 375, of the urinary tract 
during, 324-364; disturbances of appe- 
tite in, 118, of bladder in, 133, of diges- 
tive system in, 118, of hearing in. 119, 
of lower extremities in, 133, of nervous 
system in, 119, of rectum in, 133, of 
the respiratory system in, 119, of vision 
in, 119; duration of, 14S, during lacta- 
tion, 124; douches in, 193, 194; drink in, 
192; dyspnoea in, 119, 374, dysuria in, 
359; eclampsia in, 346-357; ectopic (see 
Ectopic gestation) ; ectopic and normal 
pregnancy, coexistence of , 140; eczema 
in, 324, 380; effect of measles on, 200; 
effect on fetus, of alcohol in, 293 ; effect 
on fetus of metalloids in, 293; emphy- 
sema in, 372 ; endocarditis, acute, in, 368, 
chronic, 368, 369; endometritis in, 202- 
204; enteralgia of, 366; epilepsy in, 
378; eructations in, 118; erysipelas in, 
286, 287, 379; examination in, 152-173, 
objects of, 151, under anesthesia, 182; 



1142 



INDEX. 



excitement to be avoided in, 194, 195; j 
exercise in, 191, 192; exophthalmic 
goitre in, 371; extrauterine (see Ectopic 
gestation, 404); false, 142; feigned, 142, 
fetal back, location of, 162, 163; fetal 
heart, location of, 167; fetal heart-rate 
of twins in, 167; fetal small parts, loca- 
tion of, in, 162, 163 ; fever of, 417; fibroid 
tumors in, 315; flatulence in, 118; float- 
ing kidney in, 358; fetus papyraceus 
in, 147, 148; gastric and intestinal indi- 
gestion of, 366; general phenomena of, 
118; gingivitis in, 364 ; glycosuria in, 362 , 
363; gonorrhoea in, 322; granular vag- 
initis of, 92; hair, growth of, in, 121; 
headache in, 378; heartburn in, 118, 366; 
heart, changes of, in, 118, 119; heart 
muscle, affections of, in, 369; Hegar's 
sign in, 125; hematocele in, 369; hema- 
turia in, 362 ; hemorrhoids in, 367 ; hernia 
in, 122 ; hernial protrusions of uterus in, 
313, 314; herpes in, 381, 382; hydraemia 
in, 370; hydronephrosis in, 359; hydro- 
phobia in, 289; hygiene and manage- 
ment of, 191; hyperinosis in, 120; hy- 
perosmia in, 371; hysteria in, 378; 
icterus in, 366, 367; idiosyncrasies in, 
194; impetigo in, 382; incarceration of 
kidney in, 358; incarceration of uterus 
in, 309-312; incontinence of urine 
in, 360; indigestion in, 118; indirect 
pelvimetry by measuring the sternum 
in, 185; inevitable interruptions of, 
401-403; infectious diseases in, 378-380; 
inflammation of pelvic joints in, 383^ 
influenza in, 288; injuries and accidents 
in, 416, 417; insanity of, 366, 375, 377; 
insomnia in, 377; interrupted, 385-404, 
displacements after, 398, duration of, 

394, 395", etiology of, 39 I- 393> frequency 
of, 389, hemorrhage in, 397; immediate 
dangers of. 397, neuroses following, 399, 
prophylaxis of, 399, prognosis of, 397, 
psychoses following, 399 ; recurrent inter- 
ruptions of, 392, 393, relative frequency 
of, 392, 393, remote dangers of, 398, sub- 
involution after, 398, symptoms of, 393- 

395, table of statistics of, 392, treatment 
of, 399-404; interruption of, 40, 956, 
intrauterine and extrauterine, coexist- 
ence of, 405; irritability, mental, in, 194, 
195; Jacquemier's sign of, 128, jaundice 
in, 366, 367; kidney of, 325,328; hypoder- 
moclysis in, 932 ; labia in, 91 ; lactosuria 
in, 362; latero-flexion in, 312; latero- 
version in, 312; leucocytosis in, 120; 
leucorrhea in, 192-194, 321, 322; leuke- 
mia in, 294; lineae albicantiae in, 121; 
lipuria in, 363; liver in, 119, 325; long- 
ings of, 366; lungs in, 119; malaria in, 
287, 288, 379; malformations of genital 
organs in, 315-321; mammary abscess 
in, 324; mania in, 120; manual engage- 
ment of head, 188: "mask of," 121; 
maximum duration of , 149; measles in, 
286, 379; medicated tampons to be 
avoided in, 321; melancholia in, 120; 
menstruation in, 23; menstruation sus- 
pended in, 23; mental condition in, 194; 
mercurialism in, 293; methods of exam- 
ination, in diagnosis of, 127; metric 
radiography in, 184, 185; metritis in, 



314, 315; metrorrhagia of, causes of, 
418-420; milk secretion in, 118; mineral 
acids in, effect of, on fetus, 293; molar, 
208; Montgomery's glands in, promi- 
nence of, 118; morbid appetite in, 118; 
morbidity of as related to hepatic in- 
sufficiency, 325; morphinism in, 294, 
295; multigravida, description of, 141, 
142; multiple, 144-148; eclampsia in, 
324, 346—356; murmurs, cardiac, in, 119, 
funic, in, 133, uterine, in, 127 ; nausea in 
118, and vomiting in, 366; neuralgias in, 
378; neuroses in, 378; numbness of legs 
in, 117; objects of examination in, 159, 
160; oedema in, 117, 133, 323, 324; 
operations in, 417; oral sepsis in, 365; 
osteomalacia in, 383; pains of legs in, 
117; palpation in, 127, of fetal poles, 
163, 164, of uterus, 124; paralyses in, 
377 » 3/8; pathological, 199-420; pelvic 
palpation, deep, in, 165, 166; pelvigraphy 
in, 184; pelvimetry in, external, 168— 
173, internal, 173-183, internal manual, 
181, 182, 183, Lohlein's measurement in, 
181; Rontgen, 183, 184; pelvis, external 
circumference of, 173; peptonuria in, 
362; peri-uterine inflammation and 
adhesion in, 314; pernicious anasmiain, 
370, 371; pernicious vomiting in, 366; 
phenomena produced by, in maternal 
organism, 91; phlebitis in, 369; physio- 
logical, 42, definition of, 43; pigmenta- 
tion in, 133, 134, 381, of breasts in, 118, 
of genitals in, 91 ; pining of, 366 ; pleurisy 
in, 372; plumbism in, 293; pneumonia 
in, 288,379,380; polyuria in, 362; posi- 
tion of uterus in different months of, 
129; positive signs of, 134; " pouting of 
navel " in , 122; premature interruption 
of, 385—387; preparation of patient 
in, 154; preparation of physician in, 154; 
primigravida, description of, 141; pro- 
lapse of vagina in, 322, of uterus in, 312; 
protracted, 148, 149; pruritus in, 380; 
pruritus vulvas during, 323; psoriasis 
in, 380; psychical changes in, 120; 
ptyalism in, 365; puerperal osteophytes 
in, 122; pyelitis during, 359; pyelo- 
nephritis during, 359; pyorrhoea alveo- 
laris in, 365 ; pyrosis of, 366 ; quickening 
in, 130; radiography, metric, in, 184, 
185; Rasch's sign of , 128; relapsing fever 
in, 289; relaxation of pelvic joints in, 
383; renal calculi in, 359; renal in- 
sufficiency in, 359; respiration in, 119; 
retroflexion and retroversion of uterus 
in, 308-312; Rontgen cephalometry in, 
190; rupture of uterus in, 315; saliva- 
tion in, 380; scarlatina in, 286, 379; 
sciatica in, 133; sea-sickness in, 192; 
sebaceous follicles in, 91; secretions of 
genitals in, 91; sense-perception in, 119; 
sense perversion in, 194; sepsis in, 288, 
289; sexual intercourse in, 195, 196; 
shoulder, location of anterior, 166; 
shoulder presentation, palpation in, 
167; signs of, 123, abdominal, 129, ab- 
dominal ballottement in, asymmetry of 
corpus uteri in, 128, auscultation in, 
131, 132, 133, ballottement in, 129, 133, 
Braxton-Hicks', 127, cessation of men- 
struation, 123, changes in consistence of 



INDEX. 



1143 



uterus, 125, 127, changes in volume, 
shape, and position of uterus, 124, 
classes of, 134, classification of, accord- 
ing to months, 135, 136, congestion of 
genitals, 128, cutaneous, 133, 134, 
doubtful, 134, 135, fetal, 130-133; 
Hegar's, 125, 135, intermittent contrac- 
tions, 127, Jacquemier's, 130, posi- 
tive, 134, pressure and congestion, 133, 
probable, 134, 135, quickening, 130, 
Rasch's, 128, subjective, 134, sympa- 
thetic and reflex, 133, temperature of 
genitalia, 128, umbilical murmur, 134, 
umbilical souffle, 133, uterine, 123; 
uterine fluctuation, 128, uterine mur- 
mur, souffle, or bruit, 127, uterine pulse, 
128, vaginal, 128, vaginal pulse, 129, 
vaginal secretion, 128; simulated, 142; 
skin, care of, in, 193; skin diseases in, 
380-383 ; specific vaginitis in, 322 ; spon- 
taneous rupture of uterus during, 315; . 
spurious, 142 ; sternum, measurement of, | 
in indirect pelvimetry, 185; striae atro- 
phicae after, 738; striae in breasts in, 
118; sudden death in, 416; summary of 
diagnosis of, 134; superfetation, 144, 
145; suppositories in, 193; sweat glands j 
in, 91; syncope in, 370; symptoms of 
(see Signs of) ; syphilis in, 290-292, 380; 
teeth, caries of in, 364; teeth extracted 
in, 417; temperature in, 122; tetanus in, 
289; threatened interruption of, treat- 
ment of, 400; thrombosis in, 369; tooth- j 
ache in, 365, 378; torsion of uterus dur- 1 
ing, 313; toxemia of, 324-336, acute, 
722, benign, 773, blood changes in, 330, 
chronic, 773, clinical types of, 332, 
constipation in, 329, and eclampsia dif- 
ferences between, ^33, an indication for 
premature delivery, 958, mechanical 
factors in, 329, menstrual period in, 329, 
nervous instability in, 329, poisons in, 
330, sudden death in, 332, toxic sub- 
stances and influences in, 329, treat- 
ment of, 335, 336; treatment of con- 
stipation in, 192, 193; tuberculosis in, 
289, 290, acute miliary in, 374; tumors 
removed in, 417; twin, explanation of, 
145; typhoid fever in, 287, 379; typhus 
in, 379; umbilical areola in, 121; uncon- 
scious, 143; uremia in, 345; urinary 
retention in, 360, 361 ; urine in, 120, 121 ; I 
urine examination in , 105; uterine and j 
cornual. coexistence of, 140; uterine 
asymmetry in, 128; uterine bruit in, 127, j 
128; uterine topographical relations of, 
at term, 115, 116; titerus in, 95-116; 
vaccination in, 379; vaccinia in, 286; 
vagina in, 91; vaginal examination in, 
153, 154, 173-183; vaginal mucous 
glands in, 91; vaginal pulse in, 92; 
variocosities in, 91, 117, 133, 323, 
369; variola in, 285, 286, 378. 379; 
vertigo in, 377; vesical calculi in, 
361; vesical hemorrhoids in, 361; vesi- 
cal irritation in, 359; vesical neo- 
plasms in, 361; vomiting in, 118; vul- 
val vegetations in, 323; water in, 192, 

193- 

Premature births, percentage of, 866. 

Premature labor, artificial, in pelvic de- 
formity, 716; indications for the induc- 



tion of, 957, 958; method advised for 
the induction of, 963. 

Premature rupture of the membranes, cause 
of dystocia, 662. 

Prematurity, 866-872; anuria in, 868; 
bathing in, 869; clothing in, 869,873; 
cyanosis in, .867; estimation of degree 
of, 868; etiology of, 866; feeding in, 
869-871; gavage in, 869-871 ;1 incuba- 
tion in, 871, 872; physiological peculi- 
arities of, 867, 868; prognosis of, 868; 
symptoms of, 867; temperature of 
lying-in room in cases of, 868; treat- 
ment of, 868-872. 

Prepuce, adhesion of, 862; management of, 
in newly born, 862; "stripping," 862. 

Presentation, abnormal, in multiple preg- 
nancy, 148, and prolapse of cord, 946; 
breech, 579-590; bregma, 552-555; 
brow, 555-560; cause of, 473; classifi- 
cation of, 473; definition of, 471; fre- 
quency of the several varieties of, 473; 
funicular, 576-579; multiple or com- 
pound, 613, 614; parietal, anterior and 
posterior, 571, 572; pelvic, 572-590; rel- 
ative frequency of, 574; shoulder, 590— 
597; trunk, 590; vertex, 473, 501-514. 

Primipara, 43; definition of, 27; diagnostic 
points of, 141; signs of recent delivery 
in, 747. 

Primiparae, labor in elderly, 724-726. 

Primitive streak, 53, 54, 57. 

Prochownik's, diet in pelvic deformity, 721, 
723, in pregnancy, 716-718; method of 
artificial respiration, 887. 

Proctitis, puerperal, 793. 

Prolapse of arm, 572-574; in shoulder 
presentation, sling in, 1002, 1080; pos- 
ture of mother in, 946. 

Prolapse of cord, 576-579; breech extraction 
in, 1039; podalic version in, 993, 997; 
sling in, 1080. 

Prolapse, of extremities, podalic version in 
993; of legs, 574, 576; of pregnant 
uterus, 312, 313, effect of, on fetus, 303; 
of uterus in puerperium, 768. 

Pronucleus, female, 44; male, 44 

Prophylaxis in pregnancy, 191; in puerpe- 
rium, 754-758. 

Protargol solution in ophthalmia neona- 
torum, 901, 902. 

Proteids, regulation of, in modified milk, 
855-860. 

Pruritus, hiemalis, 380; in menstruation, 21; 
in pregnancy, 380; vulvas, in preg- 
nancy, 323. 

Pryor's iodine treatment in puerperal infec- 
tion, 818, 819. 

Pseudo-fever puerperal, 810, 811. 

Psoas magnus muscle, description of, 444, 

445- 

Psoas parvus muscle, description of, 445. 

Psoriasis in pregnancy, 380. 

Psychopathic mother, offspring of, 875. 

Psychosis, acute in labor, 727; following in- 
terrupted pregnancy, 399; Korsakoff's, 
835; puerperal, 837-839. 

Ptomainemia, puerperal, 806. 

Ptyalism in pregnancy, 365. 

Puberty, 20; signs of, 20. 

Pubic ligaments, 448. 

Pubis, 424; arch of, 433. 



1144 



INDEX. 



Puerperse, care of. 41. 

Puerperal infection, 770-825; antistrepto- 
coccic serum in, 816, 817, S18; endo- 
metritis in, 782-792; orthotherapy in, 
817, 818; sapremia in, 806, 807; symp- 
toms of, 821, 822; treatment of, 815— I 
821; ulcers in, 781, 782, 801. 

Puerperium, abdominal binder, in, 755; 
abdominal muscles, diastasis of, in, 
769, 770, metastatic abscesses in, 804; 
acute specific diseases in, 772; after- 
pains in, 734, 751; air embolism dur- 
ing, 842; albuminuria in, 736; anemia 
during, anemia in, 774, 834, 835; anom- 
alies of the breasts in, 825, 826. of the 
genital tract in, 767-769, of milk secre- 
tion in, 826, 827, of pelvic articulations | 
in the, .769; antisepsis of external j 
genitals in, 749, 750; antistreptococcic 
serum in, 816, 817; aphasia in, S37; j 
asepsis in, 749 , 750,815,816; atrophy of I 
uterus during, 733; auditory paralysis 
in, 837; bacterial toxemia in. 807, 808, j 
bacteriemia in, 779, 8a8, with toxemia 
in, 809, 810; bacteria in uterus in, 778, ! 
779; bladder in, 739; blood condition 
in . 737. 834, 835; blood-states in, 806- 
8io;_ bowels in, 736; breasts, anomalies 
of, in, 825, 826; breast changes in, 
743; breasts, overdistention of , in, 812, 
813; care, of the bladder in, 751, 752, 
of the bowels in, 752, of the breasts and 
nipples in, 752; of the mother in, 750, 
catheterization in, 752; cellulitis in, 804; 
cervix and cervical canal in, 7 28 ; changes 
in uterine adnexa in, 733; changes in 
uterus in, 739-743; chill, post-partum, 
733; cholera in, 805 ;^ chronic toxemia 
not due to pregnancy in, 773 ; colostrum 
in, 743; constipation in, 764, 807, 811, 
812; corset in, 758; cystitis in, 766; 
decidua during, 742; definition of, 733; 
diagnosis of, 747 ; diastasis of abdominal 
muscles in, 769, 770; diet in, 753; diges- 
tion in, 736; diphtheria in, 80s, 808; 
diseases of breast in, 827-834: diseases 
originating intragenitally in, 804. 805; 
diseases of nervous system in, 835-830; 
duration of, 733, 754; effects of dvstocia 
in, 774; eclampsia in, 814: embolism in, 
834. 845; emotional excitement, cause ■ 
of fever in,_ 814; endometritis in, 782- 
792; ergot in, 757; eruptions of septic 
infection in, 839; erysipelas in. 805: 
examination of, 758, '816; excision of 
veins in, 820; exercise in, 757; exhaus- 
tion in, 733; external genitals in. 737, j 
738; fever in, 814, due to mammary! 
irritation in, 812, due to neurotic con- 
ditions in, 814, due to reflex irritation 
in, 814, 815, due to uterine displace- 
ments, 814, due to uterine rupture, 813, 
814; galactocele in, 834; general dis- 
eases in, 839; general phenomena in, 
733 _ 737; glycosuria in, 362; gonorrheal 
infection in, 804, 805: "heart in, 737; 
heart murmur in, 735; height of fundus 
in, 741; hematuria in, 765; hemiplegia 
and aphasia in, 837; hemorrhoids in, 
765; hyperinosis in, 737; hvperinvolu- 
tion in, 768; hvperthermia in, 810-814; j 
hypothermia in, 814, 815; hvsteria, ' 



cause of fever in, 814; impregnation in, 
747; incontinence of urine in, 754; in- 
fection, consecutive, focal in, 792-805; 
infections, primary focal in, 781-792; 
imnammations, genital, extragenital 
and perigenital in, 773-774; inflamma- 
tion of Montgomery's glands in, 827, 
829; insanity in, 837-839; intestinal 
anomalies in, 764; kidneys during, 736; 
lactosuria in, 736; metastatic lesions in, 
806; local phenomena of, 737-747; 
dochia, in 738, 739; lochiocolpos in, 775; 
management of, 748-758; massage in, 
757' 758; mastitis in, 828-834; medi- 
cation in, 757; metritis in, 794, 795; 
metrophlebitis in, 802, 803; milk secre- 
tion in, 743-747, anomalies of, in, 826, 
827; muscles in, 736, 737; morbidity in, 
770-825, _ bacteriology of, 775 _ 779, 
classification of, 771, clinical types of,' 
771, 772, 821-825; hematogenous origin 
of. 778, 779. statistics of, 770; morbid 
conditions of, antedating labor, 772- 
774, originating in, 779-821, resulting 
from labor, 774-779; mortality of, in- 
creased by chronic toxemias not due to 
pregnancy, 773; myelitis and paraplegia 
in, 837; nervous system in, 737; neu- 
ritis and paralysis in, 835-837; neuritis, 
septic, in, 808; sore nipples in, 813, 
827, 828; ocular paralysis in, 837; 
oedema of genitals in, 737; oophoritis 
in, 797; pain in genitals in, 733; para- 
metritis in, 795-797; paralysis and 
neuritis in, 835, 837; pathological, 760- 
842 ; parotitis in, 804; pelvic articula- 
tions in, 737; pelvic binder in, 755-757; 
pelvic cellulitis in, 803; pelvic peri- 
tonitis or perimetritis in, 798, 799; 
pemphigus in, 808; peptonuria in, 736; 
pericarditis in, 804; peritonitis, in, 797— 
802; phlebitis in, 802-804, femoral, 803, 
804, para-uterine, 802, 803, uterine, 802, 
803; phlegmasia alba dolens in, 803; 
physiological. 733-758; perspiration in, 
733' 735; placental site in, 742; pleurisy 
in, 804; posture in, 754, 947; primary 
thrombosis of pulmonary arteries in, 
842; proctitis in, 793; professional visits 
in, 750; prophylaxis in, 729-758; 
pseudo-fever in, 810; psychoses in, 
837-839; ptomainemia in, 806; pul- 
monary embolism in, 841, cause of 
sudden death in, 841; pulse in, 734; 
pyelitis in, 792, 793; pyelonephritis in, 
766, 767; pyemia in, 809; quinine in, 
757; recuperation in, 733; respiration 
in, 735; rest in, 750; retention of urine 
m > 736, 739- 75 1 -. 75 2 - 7 6 5! salpingitis 
in, 793; sapremia in, 806, 807; sapremic 
sepsis in, 810; septicaemia in, 809; septi- 
caemia venosa in, 802, 803; septico- 
pyemia in, 810; septic blood-states in, 
809, 810; septic erythema in, 808; 
septic neuritis in, 808; septic phlebitis 
in, 802-804; septic proctitis in, 793; 
shock from dystocia in, 744; skin dis- 
eases in, 839; skin in, 735, 736; ster- 
coremia in, 807; stomach in, 736; 
strychnine in, 757; subinvolution of 
uterus in, 767; submammary abscess 
in, 833, 834; sudden death in, 839- 



INDEX. 



1145 



842; superinvolution in, 768; syncope 
and shock cause of sudden death in, 
840, 841; tapeworm cause of fever in, 
814; temperature in, 735; test between 
normal and pathological, 770; tetanus 
in, 805 807; thirst in, 733; throm- 
bosis in, 841; thrombosis, venous, in, 
802, 803; toxemia of pregnancy per- 
sistent in, 773; tuberculosis in, 774; 
tympanites in, 764; ulcerative endo- 
carditis in, 809; urea excretion in, 736; 
urethritis, cystitis, pyelitis and pyelo- 
nephritis in, 792; urinary anomalies 
in, 765; urinary retention in, 736, 739, 
751. 752, 765; urine in, 736; uterine 
adnexa in, 743; uterine displacement 
in, 768; uterine involution in, 739-743; 
uterine muscle in, 742 ; uterine position 
in, 741; uterine souffle in, 735; uterine 
vessels in, 742; vagina in, 738; variola 
in, 805; vulval dressings in, 750. 

Pulmonary, artery, fetal, 81; arteries, prim- 
ary thrombosis of, in puerperium, 842 ; 
disease, dystocia due to, 727; embolism, 
cause of sudden death in puerperium, 
841. 

Pulse, funic, 77; in accidental hemorrhage, 
^40; in colic of newly born, 920; in con- 
vulsions of newly born, 923; in eclamp- 
sia, 398; of newly born, 847; in malig- 
nant peritonitis, 801; in puerperal 
fever, 814; in puerperal infection, 821, 
822; in insanity of puerperium, 838; 
in labor, 481; in prematurity, 867, 868; 
in puerperium, 734, 751; in pulmonary 
embolism, 841; in septic infection of 
newly born, 907; in tetanus of newly 
born, 911; vaginal, in pregnancy, 92, 
129; in sapremia, 806; in septicemia, 
809; uterine, in pregnancy, 128. 

Pupillary membrane, disappearance of, 85. 

Purgatives, in colic of newly born, 920; in 
convulsions of newly born, 923; in diar- 
rhea of newly born, 919; in pyelone- 
phritis, 358; in threatened eclampsia, 

353- 

Purpura hemorrhagica of newly born, 916. 

Purpura, puerperal, 839. 

Putrefaction of fetus, 306. 

Pyelitis in puerperium, 792, 793. 

Pyelonephritis, in pregnancy, 358; in puer- 
perium, 792, 793. 

Pyemia, a result of curettage, 819; puer- 
peral, 809, types of, 824, 825. 

Pylorus, congenital hypertrophic stenosis 
of, .295, 875. 

Pyogenic cocci in bacterial toxemia, 807. 

Pyogenic foci, limitation of, to birth tract, 
823. 

Pyometra, diagnosis of, from pregnancy, 136. 

Pyorrhoea alveolaris in pregnancy, 364. 

Pyosalpinx, and pregnancy, coexistence of, 
141. 

Pyriformis muscle, 447. 

Pyrosis of pregnancy, 366. 

Pyrozone in puerperal ulcers, 782, 



Quickening, in pregnancy, 130; its relation 
to the vomiting of pregnancy, 357 



Quinine as accelerator of first stage of labor, 
628, 629; in malaria of pregnancy, 288; 
in puerperal infection, 817; in puer- 
perium, 757. 

R. 

Races, intermarriage of, factor in maternal- 
fetal dystocia, 715. 

Rachidotomy, 1015. 

Rachitic pelves, 687-692. 

Rachitis (see Rickets) . 

Radiography, metric, 184, 185. 

Rales in lungs of newly born, 842. 

Ranula of newly born, 919. 

Rape, 30-36. 

Rasch's sign in pregnancy, 128. 

Rauber's layer, 53, 63, 64, 65. 

Reaction of feces of newly born, 847, 848; of 
menstrual blood, 24. 

Rectal, feeding in pernicious vomiting of 
pregnancy, 343; infusion of saline solu- 
tion, 929, 930; syringes for newly born, 
921. 

Recti, separation of, in puerperium, 769, 770. 

Rectocele, cause of dystocia, 672. 

Rectum, abnormalities of, 276; changes in, 
in pregnancy, 117; congenital stricture 
of, 276, 277; disturbances in, in preg- 
nancy, 133 ; distended, cause of dystocia, 
671 ; repair of, 1102, 1103. 

Reflex irritation a cause of hyperthermia, 
811-814. 

Reichert's ovum, 68. 

Relapsing fever in pregnancy, 289; of fetus, 
289. 

Renal calculi in pregnancy, 359. 

Renal disease, effect of, on fetus, 294. 

Renal insufficiency in pregnancy (see Tox- 
emia of pregnancy). 

Rennet, action of, 745. 

Reposition, in prolapse of umbilical cord, 

5/8, 579- 
Repositors for prolapsed small parts, 986. 
Reproduction, indications for prevention of, 

3.9- 

Respiration, artificial, in prematurity, 869; 
causes of establishment of, 845; estab- 
lishment of, in newly born child, 541; 
in convulsions of newly born, 923; in 
labor, 481 ; in newly born, establishment 
of, 845, 846; in prematurity, 867, 868; 
in puerperium, 735, 751; in septic in- 
fection of newly born, 907; in tetanus 
of newly born, 913; rate of, at birth, 
845 ; restoration of, in asphyxia neona- 
torum, 884-889. 

Respiratory system, diseases of, in preg- 
nancy, 371-374. 

Rest, in puerperium, 750; in puerperal 
parametritis, 799; in puerperal perime- 
tritis, 799; in puerperal phlebitis, 803, 
804; in pulmonary embolism, 841. 

Retained placenta, 630-633. 

Retention of urine in puerperium, 736, 739, 
751, 752, 765. 

Retina, formation of, 55; origin of, 61. 

Retraction of the uterus, 626. 

Retraction ring (see Contraction ring). 

Retroflexion and retroversion of uterus in 
puerperium, 768. 

Retroflexion of uterus, diagnosis of, from 



1146 



INDEX. 



pregnancy, 139; m pregnancy, 307-311; 
and incarceration, an indication for in- 
duction of abortion, 956. 

Retropharyngeal abscess in newly born, 910. 

Retroversion of uterus, diagnosis of, from 
pregnancy, 139; in pregnancy, 308-312. 

Rheumatism in newly born, 874; of fetus, 
289; of uterine muscle in pregnancy, 

3*4- p ... 

Rickets, 687-692; cause of constipation m 
newly born, 921; cause of convulsions 
in newly born, 923; fetal, 875; in lower 
animals, 688. 

Rigidity and atresia of vagina and vulva, 
cause of dystocia, 668-672. 

Ring, Bandl's, 227, 452; contraction, 451 ; 
retraction, 451; umbilical, 846. 

Ritgen's method of extracting fore-coming 
head, 1036. 

Ritter's disease, 910. 

Robert's pelvis, 683. 

Roederer's obliquity, 503, 551. 

Rokitansky, on cervical pregnancy, 206; on 
puerperal osteophytes, 122; pelvis of, 
698-701. 

Rontgen, cephalometry, 190 ; pelvimetry, 183. 

Rostrate pelvis, 692. 

Rotation, digital, in transverse position of 
head at pelvic outlet, 608, 609; exces- 
sive, of occiput, in vertex presentation, 
506; exerted by forceps, 1058; of fetal 
head, 463 ; of first part of fetal ellipse in 
labor, 492-497; of second part of fetal 
ellipse in labor, 497; posterior, of occi- 
put, and impaction, 510, 511. 

Rotators, forceps as, 1073, 1074. 

Round ligaments, changes of, in pregnancy, 
114. 

Rowbotham's diet in pregnancy, 716. 

Rubber gloves, 157. 

Rupture of membranes, premature, dysto- 
cia from, 662; of the membranes, tardy, 
dystocia from, 662 ; of the pelvic floor, 
muscular, 654; spontaneous, of uterus, 
in pregnancy, 315; submucous, 654. 

Rupture of uterus, 641-647; celiotomy in, 
1097 ; following ventrofixation of uterus, 
657; in contracted pelvis, 713; in preg- 
nancy, 641-647 ; in pregnancy in cancer- 
ous uterus, 667; in puerperium, 641; 
intra-partum, 641. 

S. 

Sac, amniotic, 66. 

Sacral plexus, lesions of, during puerperium, 

Sacro-coccygeal ankylosis, symphyseotomy 

in, 1006. 
Sacro-coccygeal joint, 426, synostosis at, 

697; ligaments, 448; tumors, 284, 285, 

cause of dystocia, 621. 
Sacro-iliac joints; diastasis of, in labor, 673; 

movements in, 426; synostosis at one or 

both of, 697. 
Sacro-posterior cases, persistent, delivery of 

head in, 1051— 1053. 
Sacro-sciatic ligaments, 448. 
Sacro-vertebral, angle, 426; joint, 426. 
Sacrum, 423, 424; imperfect development of 

both lateral masses of, 683, 684; of one 

lateral mass of, 680; movement of, 427. 



I Sadler's law in sex-control, 91. 

! Saline infusion, 929; intra- arterial 930; in- 
travenous, 930, 931; in eclampsia, 353, 
354; preparation of solution for, 929; 
in puerperal infection, 817; umbilical, in 
asphyxia neonatorum, 888; rectal, in 
shock, 929, 930; vaginal and intrauterine, 

95°- 
Salines, in overdistention of breast, 813; in 

puerperal constipation, 811. 
Salivation in pregnancy, 365. 
Salpingitis, puerperal, 793. 
Saponification of fetus, 306. 
Sapremia, antepartum, 772; puerperal, 784, 

785, 806, 807, 822, 823; in relation to 

sexual functions, 37. 
Saprophytes in puerperal endometritis, 783- 

785- 

Sarcoma, fetal, 301; pelvic, 696. 

Saw decapitator, 1028. 

Scales, baby, 853. 

Scanzoni's, cephalotribe, 1022; manoeuvre, 
1077. 

Scarlatina of fetus, 286; in newly born, 873; 
in pregnancy, 286. 

Schatz's external method of correction of 
bregma, brow, and face presentations, 
570, 980, 981. 

Scheele's method of abortion, 961. 

Schenk's general method, of analysis and 
diet, in relation to sex-control, 87, 90, 
192, 362. 

Schultze's, measurements of embryo and 
fetus, 86, 88, 89; method of artificial 
respiration, 886; method of placental 
delivery, 489-490; sickle hook, 1025, 
1026. 

Sciatica, in pregnancy, 133. 

Scissors, decapitation, 1029. 

Sclerema neonatorum, 917. 

Sclerosis of placenta, 248. 

Scoliotic pelvis, 705. 

Sebaceous follicles in pregnancy, 91. 

Secundines, retention of, 545. 

Sedatives for newly born, 923, 925; in in- 
sanity of puerperium, 839; in puerperal 
neuritis, 836; in threatened abortion, 
400; in painful labor, 629. 

Segmentation of the ovum, 53. 

Semen, 27. 

Semmelweiss on puerperal fever, 152. 

Senator on osteomalacia, 693. 

Senses, acute, in pregnancy, 119; perversion 
of, in pregnancy, 194. 

Separation of pelvic joints, exaggerated, 698. 

Sepsis, acute, 824; bacteria of puerperal, 
153-809; composite, 809, 810; a sequel of 
labor in typhoid fever, 379; conditions 
which predispose to, 786; fetal, 288, 
289; in newly born, 874; in pregnancy, 
288, 289; in relation to psychoses in 
pregnancy, 377; neonatorum, 908; puer- 
peral, gas, 810; puerperal, sapremic, 
790, 810; saline infusions in, 930. 

Septa, decidual, origin of, 70; of vagina, a 
cause of dystocia, 669. 

Septic coryza of newly born, 908, 909. 

Septic infection in interrupted pregnancy, 
398, of newly born, 906-908, puerperal 
organisms causing, 785, puerperal, 
treatment of, 790-792, neuritis, puer- 
peral, 808; pemphigus of newly born, 



INDEX. 



1147 



808; phlebitis, 802 ; pneumonia of newly 
born, 874, 909. 

Septicaemia, 823-825; as a clinical phenom- 
enon, 824, 825; primary focus of puer- 
peral, 822; puerperal, 809; puerperal, 
non-metastatic, 808; venosa, puerperal, 
802, 803. 

Septicopyemia, puerperal, 787, 810. 

Serotina, decidual, 46; placental, 46 

Serous cachexia in pregnancy, 370. 

Serotherapy in puerperal infection, 817, 818; 
in puerperium, 816. 

Serum, antistreptococcic, in puerperal infec- 
tion, 817, 818; in puerperium, 816. 

Sex control, experiments in, 87; heredity in 
relation to, 91; Hofacker's law in, 91; 
Sadler's law in, 91; Schenk's diet in 
relation to, 90; Schenk's method of, 
87, 90; Starkweather's law in, 91. 

Sex, determination of, 86, 87; evolution of, 
86 ; of fetus, indication of, by heart rate, 
167; variation of weight of newly born, 
due to, 850. 

Sexual, intercourse, and abortion, relation 
between, 196; effect of, on health, 39; 
effect of, on menstruation, 23; effect 
of, on ovulation, 17; in pregnancy, 195, 
196; life, 39; excitement, as affecting 
menstruation, 23, in relation to sexual 
functions, 37; functions, hygiene of, 

37- 

Shell-fish as milk producers, 826. 

Shock, enteroclysis in, 932; from dystocia, 
774; from post-partum hemorrhage, 
treatment of, 640, 641; treatment of, 
in asphyxia neonatorum, 888. 

Short cord, posture of mother in, 946. 

Shoulder, diagnosis of, from breech, 1002; 
extraction in head-first cases, 1037, 
1038; great width of, cause of dystocia, 
620; location of anterior, in pregnancy, 
166. 

Shoulder presentation, 590-597; bipolar 
podalic version in, 994, 995; combined 
cephalic version in, 991; definition of, 
990, 991; diagnosis of , 595, 596; etiology 
of, 590-592; evisceration in, 1030; fre- j 
quency of, 591; mechanism and course 
of labor in, 592, 593; palpation in, 167; \ 
podalic version in, 993; prognosis of, 
596, 597; sling in, 1080; synonyms of, 
590; treatment of, 597; varieties and 
relative frequency of, 592; version in ! 
impacted. 1004. 

Shoulders, delivery of, 508, 538-540, T037. 

Show, in labor, 481, 485. 

Sickle knife decapitator, 1028, 1029. 

Signs of pregnancy, 123. 

Silver nitrate, as preventive of ophthalmia, 
542; in aphthae of the newly born, 913; 
Crede's collodial in endometritis, 791; | 
in ecthyma neonatorum, 911; in gonor- 
rheal stomatitis, 903 ; in leucorrhea, 194; 
in ophthalmia neonatorum, 900-902 ; 
in treatment of sore nipples, 828; in 
umbilical sepsis, 908; solution in treat- 
ment of eyes of newly born, 900. 

Simple, flat, rachitic pelvis, 689; non-rachit- 
ic pelvis, 677-679. 

Simpson's, cranioclast, 1016; forceps, 1056. 

Sims', dilator, 971; knee-chest posture, 940. 

Sinciput, 461; fetal, 459. 



Sinus, urogenital, origin of, 61; uteri, 109. 

Sinuses, maternal, 70. 

Skiagraphy, pelvic, 184. (See Rontgen 
Pelvimetry and Rontgen cephalometry.) 

Skin, care of, in pregnancy, 193, in relation 
to hygiene of sexual functions, 37; 
changes of , in pregnancy, 121; diseases, 
in pregnancy, 380-383, in utero, 297, 
in puerperium, 735, 736; formation of, 
54, 57; in fetal syphilis, 291. 

Skull, defects of formation of, 274, 275 ; fetal, 
measurements of, 186-190, premature 
ossification of, 619. 

Skutsch's pelvimeter, 177. 

Sleep after completion of third stage of 
labor, 548; for newly born, 861. 

Sling, indications and uses of, 1078, in pelvic 
presentation, 1079, in placenta praevia, 
1079, i n prolapse of cord, 1079, in pro- 
lapse of an arm in shoulder presentation, 
1003, 1004, 1080, in combined podalic 
version, 1080. 

Small parts, fetal, location of, by palpation, 
162, 163; reposition of prolapsed, 984, 
987. 

Small round pelvis, 676, 677. 

Smallpox. (See Variola.) 

Smell, sense of, acute in pregnancy, 119. 

Smellie's, forceps, 1054; method in breech 
presentation, 1046-1050. 

Smellie-Veit method in breech presentation, 
1049, io 54- 

Sneguireff's method of vaporization in septic 
endometritis ,821. 

Sodium bicarbonate in sterilization of instru- 
ments and dressings, 02 9. 

Sodium borate solution in catarrhal con- 
junctivitis, 900. 

Solayre's obliquity, 502. 

Somatopleura, 61, 65, 68, 71; extra-embry- 
onic villi of, 46; formation of, 57. 

Souffle, funic, in pregnancy, 133; uterine, 
in pregnancy, 127, 128, in puerperium, 
735. (See Murmur.) 

Spee's embryo, dimensions of, 83. 

Spermatic fluid, 29. 

Spermatozoa, 28, 29 ; as affected by acids, 28, 
by alcohol, 28, by alkalies, 28, by cold, 28, 
by heat, 28, by sexual excess, 28; appear- 
ance of, 28; ascent of , 29; disappearance 
of, 28, motion of, 28, 29; normal age for 
production of, 28; rate of motion of , 28; 
theories of ascent of, 29; vitality of, 28, 
29. 

Sphincter ani muscle, external, 448. 

Sphincter, rectal, repair of, 1102, 1103. 

Spina bifida, 275, 276. 

Spinal, anesthesia in labor, 936; cord, origin 
of, 61; disease in relation to labor, 727. 

Spine, curvature of, from high heels, 39; de- 
fects information of, 274-276; puncture 
of, in congenital hydrocephalus, 619. 

Splanchnic inversion, 260. 

Splanchnopleure, 63, 65; formation of, 58; 
origin of, 61. 

Spleen, changes of, in pregnancy, 119; 
effect of hepatic insufficiency on, 326; 
floating, cause of dystocia, 661, diagnosis 
of. from pregnancy, 140, 141; in septic 
infection of newly born, 907 ; rupture of, 
in labor, 728. 

Splenotribe, 1025. 



1148 



INDEX. 



Spondylolisthesis, 698-701. 

Spondylolizema, 701, 702. 

Spondylotomy, 1033. 

Spurious pregnancy, 142. 

Stages of labor, 483-491. 

Staphylococci in human milk, 855; in puer- 
peral sepsis, 153; in vulval canal, 153; 
sepsis of fetus, 288, 289. 

Starkweather's law in sex-control, 91. 

Stenosis of cervix, vaginal Csesarean section 
in, 1088. 

Stercoremia, puerperal, 807. 

Sterility after abortion, 399; artificial, 39; 
facultative, 39; following coitus inter- 
ruptus, 40; from anterior displacement 
of uterus, 308; from retroversion of 
uterus, 308; posture an aid in, 944. 

Sterilization of instruments and dressings, 
928, 929; of milk, 855, 856, 858, 859, 
general directions for, 858, 859. 

Sternomastoid, hematoma of, 897. 

Sternum, measurement of, in indirect pel- 
vimetry, 185. 

Stimulants for newly born, 925; in malig- 
nant peritonitis, 802; in prematurity, 
871; in puerperal infection, 817; in puer- 
peral syncope and shock, 840 ; in puer- 
peral thrombosis and embolism, 834; in 
pulmonary embolism, 841. 

Stoltz's, sign, 304 ; test for vaginal hernia, 726. 

Stomach in puerperium, 736, 753. 

Stomatitis, gangrenous, of newly born, 909; 
gonorrheal, 902, 903; ulcerous, of newly 
born, 909; vesicular or follicular of 
newly born, 913. 

Stools of newly born. (See Feces of newly 
born.) 

Strait, inferior, definition of, 433; superior, 
definition of, 430. 

Streak, primitive, 53, 54, 57. 

Streptococcus erysipelatis, 912; in puer- 
peral sepsis, 153; in vulval canal, 153; 
sepsis of fetus, 288. 

Strias, abdominal, in pregnancy, 129; atro- 
phicas, after pregnancy, 738; of breast 
in pregnany, 118. 

Stricture of vagina, cause of dystocia, 669. 

Strychnine after abortion, 403 ; in asphyxia 
neonatorum, 888; in eclampsia, 354; in 
erysipelas of the newly born, 912; in 
heart disease of pregnancy, 368; in last 
weeks of pregnancy, 629; in puerperal 
infection, 817; in puerperium, 757. 

Studdiford on levator ani muscle, 447. 

Stump, umbilical, 846. 

Subcutaneous or American method of sym- 
physeotomy, 10 10. 

Subinvolution and improper diet, relation 
between, 192. 

Subinvolution, after interrupted pregnancy, 
398; diagnosis of, from pregnancy, 137; 
in puerperium, 767, 768. 

vSublimate solution, in intrauterine irrigation, 
951; in ophthalmia neonatorum, 901; 
in vaginal and intrauterine infections, 

o 95 °- 

Sublingual cysts in the newly born, 919. 

Sudamina, puerperal, 839. 

Sudden death, in pregnancy, 332, 416; 
accouchement force in, 1035, podalic 
version in, 993; in puerperium, 839- 
842 ; of newly born. 924, 925. 



symphyseotomy, 



1090. 
(See 



Ob- 



461, 851; 
repair of 



Sugar, regulation of, in modified milk, 855- 
861. 

Superfetation, 144, 145. 

Suprapubic method of 
1008, 1009. 

Supravaginal hysterectomy, 1089, 

Surgery, obstetric, 927-1103. 
stetric surgery.) 

Sutures, cranial, of fetus, 460, 
surgical, removal of, after 
pelvic floor, 1 103. 

Sylvester's modified method of artificial 
respiration, 887. 

Sympathetic nerves and genital system, 
relation between, 25. 

Sympathetic nervous system in relation to 
ovulation, 17. 

Symphyseotome, Spinelli's, 1009. 

Symphyseotomy, 1006-1010; French or open 
method of , 1009, 1010; in breech presen- 
tation, 1042; in brow presentation, 560, 
561; in funnel-shaped pelves, 679; in 
kyphosis, 705; in pelvic deformity, 716, 
718-728; in persistent mento-posterior 
positions, 605-608; in transverse posi- 
tion of head at pelvic outlet, 610; 
in transverse engagement of head in 
inlet in deformed pelves, 605, 608; indi- 
cations for, 1006, 1007; Italian or supra- 
pubic method of, 1008, 1009: morbidity 
of, 1007; mortality of, 1007, 1008; oper- 
ation of, 1 008-10 10; subcutaneous or 
American method of, 10 10. 

Symphysis pubis, 424; changes of, in preg- 
nancy, 117; measurement of length of, 
in pregnancy, 172; mobility of, in preg- 
nancy, 425; synostosis at, 697. 

Syncope and shock, cause of sudden death 
in puerperium, 840, 841, treatment of, 
840, 841; following labor, 636; inhydati- 
diform mole, 211 ; in pregnancy, 370. 

Synostosis, at sacro-iliac joints, 697 ; at sacro- 
coccygeal joint, 697; at symphysis, 697. 

Syphilis, an etiological factor in fetal death, 
304; cause of interrupted pregnancy, 
391, 392; congenital, 292, 875; in fetus, 
290-292, 875; in pregnancy, 290—292, 
380; indication for prevention of repro- 
duction, 39; infantile, 875, 876-878, 
diagnosis, 876, prognosis, 876, 877 
treatment, 877, 878; of placenta, 247, 
248; of umbilical cord, 256; treatment 
of, in pregnancy, 292; transmission of 
to fetus, 291. 

Sweat glands, in pregnancy, 91. 



T. 

Tactile organs, origin of, 61. 

Tampon, uterine, 953, 955; uterine and cer- 
vical, 970; vaginal, 952, 953, 960, medi- 
cated, contraindicated in pregnancy, 322. 

Tamponade, in inversion of uterus, 648; in 
placenta prasvia, 234, 235, 352; in rup- 
ture of uterus, 646, 647; of uterine cav- 
ity, 960; of vagina and cervix, 960. 

Tapeworm, a cause of fever in puerperium, 
814. 

Tarnier-Auvard incubator, 873. 

Tarnier clinic, statistics of, on labor in 
elderly primiparae, 725. 



INDEX. 



1149 



Tarnier's, embryotome, 1025; forceps, 1055, 
1056, 1057; incubator, 87 1; sign of 
abortion, 395. 

Taste, delicacy of, in pregnancy, 119. 

Taste, organs of, origin of, 61. 

Teeth, caries of, in pregnancy, 364; devel- 
opment of, 84; extraction of, in preg- 
nancy, 417. 

Temesvary's statistics on pulse in puer- 
perium, 734; table of height of fundus 
in puerperium, 741. 

Temperature, change of, in pregnancy, 120; 
constipation a cause of irregular, 811; 
mammary irritation a cause of , 8 1 2 , 8 1 3 ; 
in labor, 481, in puerperium, 735, 751; 
fetal, 847; in eclampsia, 348;^ in preg- 
nancy, 122; in puerperal infection, 
821; in relation to sex control, 87, 90; 
in sclerema neonatorum, 917; of geni- 
talia, in pregnancy, 128; proper, for in- 
cubator, 872, 873; of lying-in room for 
premature child, 868; of newly born, 
847; of nursery, 861; of premature 
child, 867; a test between normal and 
pathological puerperium, 770; sub- 
normal (see Hypothermia) . 

Tenesmus, vesical, in pregnancy, 117. 

Testicles, descent of, into scrotum, 85; 
ectopia of, 278; retention of, in ab- 
dominal cavity, 278. 

Tetanus, after interrupted pregnancy, 398; 
bacterial toxemia of, 807; in preg- 
nancy, 289; of newly born, 912, 913; 
puerperal, 805, 822. 

Thomas's embryotome, 1025. 

Thomson on evolution of sex, 87. 

Thorax, formation of, 58. 

Thorny pelvis, 695. 

Thrombosis, in pregnancy, 369; infected, 
766-769; of placenta, 243-246; of pul- 
monary arteries, primary, puerperal, 
802, 803, 842; umbilical, 254; vaginal 
and vulval, cause of dystocia, 670. 

Thrush of newly born, 913. 

Thymus gland, in fetal syphilis, 291, origin 
of, 61. 

Thyroid extract in osteomalacia, 693. 

Tissues derived from each germ-layer, 
61. 

Tocodynamometer, 481. 

Tocology, 716. 

Tonics in puerperal anemia, 835. 

Toothache in pregnancy, 365, 378. 

Topography, uterine, at term, 115, 116. 

Torsion of pregnant uterus, 313. 

Touch, sense of, acute, in pregnancy, 119. 

Toxemia, bacterial, 823; clinical course of 
malignant, 824, and fever, without 
sepsis, 823; a cause of interrupted preg- 
nancy, 391, 392; of pregnancy, 324- 
336, persistent in puerperium, 772, 
773, blood in, 328, clinical types of, 332, 
Ewing's theory of, 327, Dermosier's 
theory of, 326, Hertz's theory of, 326, 
kidney in, 328, liver in, 328, spleen 
in, 328, pernicious vomiting in, 327, 
an indication for premature delivery, 

95.8- 
Toxemias, chronic, in puerperium, not due 

to pregnancy, 773. 
Tracheotomy in asphyxia neonatorum, 883. 
Tract, genital, three parts of, 153. 



Traction, by forceps, 1057, 1069-1081. 

Traction-straps in labor, 630. 

Transverse diameter, of pelvis, 431; of 
pelvic cavity, 433; of pelvic outlet, 434. 

Transverse engagement of head in inlet in 
deformed pelves, 605. 

Transverse head, forceps in deep, 1077. 

Transverse position, 590; high, 287; mechan- 
ism in simple flat pelves, 605, 608; of 
the head at pelvic outlet, 608, 609; pre- 
sentation, 590-597. 

Transversely contracted pelvis, 683, 684. 

Transversus perinei muscle, 448. 

Traumatism, fetal, 300; in etiology of acci- 
dental hemorrhage, 239; fetal, birth, 
889-893, maternal, 775; of brain and 
cord, at birth, 889, 890; of nerve-trunks 
at birth, 890-893; surgical treatment 
of, after labor, 515, 516. 

Trendelenburg posture, 942, 943, 947. 

Trendelenburg- Walcher posture, 947. 

Trephining in depressions or indentations 
of cranial bones, 893, 894. 

Triple labor, management of, 613. 

Trismus uteri, cause of dystocia, 663. 

Trochanters, pelvic diameter between great, 
in pregnancy, 169, 170. 

Truncus arteriosus, 78. 

Trunk, development of, 53; dystocia from 
affections of, fetal, 621; expulsion of, 
in labor, 540; in normal delivery, 508; 
internal rotation of, in labor, 497; 
monstrosity, 279; presentation, 590; 
rotation of, in labor, 512. 

Tubal abortion, pathology of, 407, 408; preg- 
nancy, 404, 405, pathology of, 406, 407, 
recurrence of, in other tube, 405, 406, 
bilateral, 406. 

Tube, eustachian, 61; neural, 54, 55, 56. 

Tuberculosis, acute miliary, in pregnancy, 
374; cause of interrupted pregnancy, 
392, and pregnancy, 289, 290, 372—374; 
in newly born, 874, 875; an indication 
for premature delivery, 374; in puer- 
perium, 774; an indication for pre- 
vention of reproduction, 39; of fetus, 
289, 290; of placenta, 247; pregnancy 
a predisposing cause of, 372, 373. 

Tuberculous toxemia, fetal, 289, 290. 

Tubes, ovarian, condition of, in menstru- 
ation, 21; distended, diagnosis of, from 
pregnancy, 140. y^ 

Tubo-abdominal pregnancy, 404. £-, 

Tubo-ovarian pregnancy, 405 ; pathology of, 
408. m 

Tumors, abdominal and pregnancy, coex- 
istence of, 141; congenital, of umbilical 
cord, 257; inoperable, indication for 
prevention of reproduction, 39; origi- 
nating in urinary apparatus, cause 
of dystocia, 620; ovarian, and preg- 
nancy, coexistence of, 138, 139, 141, 
diagnosis of, from pregnancy, 138; 
pelvic, 696, and pregnancy, coexistence 
of, 141, prognosis of, 696, treatment of, 
696; placental, 251 ; removal of, in preg- 
nancy, 417; sacro-coccygeal, 284, 285, 
dystocia due to, 621; uterine, ovarian, 
renal and peritoneal, cause of dystocia, 
659-662. 

Twin labor, hemorrhage after first birth, 
612; management of, 610-613. 



1150 



INDEX. 



Twin monstrosities, general fetal oedema in, 

3°3- . tJ , 

Twin pregnancy, common m elderly primi- 
parae, 724; diagnosis of, from hydram- 
nios, 218; in Fallopian tube, 406. 

Twins, abnormal conditions in, 147; expla- 
nation of, 145; fetal acardia in, 147; 
fetal heartbeat in, 167; homologous 
normal, 281; management of fetal 
membranes of, 145, 146; separate, 281; 
united, 282. 

Typhoid fever in pregnancy, 287; of fetus, 
287. 

Typhus, fetal, 289; in pregnancy, 379. 

U. 

Ulcer, puerperal, 781, 782. 

Ulceration of hard palate in newly born, 

9 Z 9- 
Umbilical arteries, fetal, 81; thrombi in, 

254. 

Umbilical cord, 71; adenoma of, 257; 
anomalies of, 252; arteries of, 77; arte- 
rial valves of, 77; atheroma of, 257; 
battledore insertion of, 252; calcareous 
deposits in, 255; care of, 538, 852; cen- 
tral insertion of, 252, 253; coils of, 253, 
about neck of child, 538; cysts of, 255; 
dermoid of, 257; development of, 71; 
diameter of, 77; dressing for, 852; ec- 
centric insertion of, 252, 253; endar- 
teritis of, 256; endophlebitis of, 256; j 
entero-teratoma of, 257; epithelium of, ! 
71 ; excessively long, 614; false knots in, 
73; formation of, 58; function of, 71, j 
77; haematoma of, 256; hemorrhage ! 
from, 256; hernia of, 256; hypertrophy 
of valves of, 256; infection of, 908; in- 
sertion of, 252; knots of, 253, 254; lat- 
eral insertion of, 252; length of, 77, 252; 
ligation of, 541, 542; in prematurity, 
868; loops of, 253; marginal insertion 
of, 253; obstruction of vessels of, 256; 
origin of, 65, 71; periarteritis of, 256; 
periphlebitis of, 256; prolapse of, 574- 
579, in contracted pelvis, 713; pulse of, j 
77; reposition of prolapsed, 984, 1080; 
rupture of, 615; short, 614, 615, symp- ' 
toms and treatment of, 614, 615; 
shortest on record, 77; spiral aspect of, 
77; stenosis of vessels of, 254; strength 
of, 77, structure of, 71 ; syphilitic lesions 
of, 256; tangling of , 254; tensile power 
of, 77; thickness of, 252; torsion of, 
254; traction on, cause of inversion of j 
uterus, 647; tumors of, 257; veins of, 
77; velamentous insertion of, 252, 253; 
venous valves of, 77. 

Umbilical hernia, congenital, 273, embry- 
onic, 273. 

Umbilical, infusion in asphyxia neonatorum, 
888; sepsis, 908; stump and ring, 846, 
847; vein, 81, 82, dilatation of, 2 5 6, peri- 
phlebitis of, 254; vesicle, 71. 

Umbilicus, adenomata of, 257; atheromata 
of, 257; congenital tumors of, 257; 
dermoids of, 257; difference between 
male and female, 847; entero-terato- 
mata of, 257; murmur of, in pregnancy, 
133; variation in position of, in preg- 
nancy, 150. 



Unconscious delivery, 500. 

Undeveloped pelvis, 679, 680. 

Unilateral club-foot, 711. 

Urachus, origin of, 68; persistent, 278. 

Urea, changes in, in relation to eclampsia, 
350, 351; excretion of, in menstruation, 
21, in puerperium, 736; in liquor amnii, 
66. 

Uremia in pregnancy, 345 ; and eclampsia, 
difference between, 345. 

Ureter, changes in, in pregnancy, 117. 

Urethra, malformations of, 320; origin of, 
61. 

Urethritis, pyogenic puerperal, 792, 793. 

Urinary, anomalies in puerperium, 765; 

meatus, narrowness of, 276; organs, 

origin of, 61; retention, in pregnancy, 

360; tract, diseases of, in pregnancy, 324, 

.364; tract, puerperal infection of, 792, 

Urination m puerperium, 736. 

Urine, analysis of, in relation to sex-control, 
90; examination of, in pregnancy, 195, 
350; fetal excretion of, 66, 67; fetal, 
albumin in, 79; in cystitis, 766; in 
eclampsia, 349; in newly born, 848; in 
pregnancy, 120, 121, importance of 
examination of, 195, 350; in pregnancy- 
kidney, 325; in puerperium, 736, re- 
tention of, 736, 739, 751, 752; inconti- 
nence of, in pregnancy, 117, 360, in 
distended bladder, 138; prenatal color- 
ing matters of, 67; toxicity of, 350, 351. 

Urogenital apparatus, fetal diseases of, 
296. 

Urogenital system, origin of, 58, 59. 

Urotropin in puerperal cystitis, 793. 

Uterine, and cervical tampon, 970; com- 
pression in breech extraction, 1046; 
disease, maternal, effect of, on fetus, 
303; displacements in puerperium, 768, 
769; exhaustion, 625, 627; inertia, 625- 
630, cause of intra-partum hemorrhage, 
730; irrigation in puerperal infection, 
817; myoma, cause of dystocia, 659- 
661; tampon, 953-955. 

Utero-ovarian amputation in osteomalacia, 

TT 383. 384. 

Utero-sacral ligaments, changes m preg- 
nancy, 114. 

Uterus, absent, 316, 317; accessory, 319; 
anteflexion and anteversion of, in preg- 
nancy, 307, 308; asymmetry of, in 
pregnancy, 104, 128; axial rotation 
of, causes of, 477; backward displace- 
ments of, 308-312; bacteriology of 
cavity of, 777-779; Bandl's ring of, 
452; bicornis, pregnancy in, 414, 415; 
bilobed, pregnancy in supplementary 
horn of, 405; cancer of, cause of 
dystocia, 667; capacity of, at fortieth 
week, 733, at end of puerperium, 733; 
catheterization of (Krause's method), 
958-960; celiotomy in rupture of, 1097; 
changes of, in labor, 480, in menstrua- 
tion, 21, in pregnancy, 93-116, in 
arteries of, 109, no, in, in axis of, 105, 
106, in consistence of, 106, 125, 127, in 
contracility of, 115, in fibrous tissue 
of, 109, in irritability of , 115, in liga- 
ments of, 113, 114, in lymphatics of, 
112, in nerves of, in, 112, in muscular 



INDEX. 



1151 



layers of, 106, 107, in peritoneum of, 
112, in position of, 105, 106, in sensi- 
bility of, 114, 115, in shape of, 103, 104, 
in situation of, 105, 106, in size of, 96, 
97, 102, 103, in veins of, 109, no, in 
volume of, 96, 97, 102, 103, in walls 
of, 115; changes of, in puerperium, 733, 
739-743; condition of, in puerperium, 
751; congenital prolapse of, 296, 319; 
congenital retroflexion of, 319; con- 
gestive hypertrophy of, diagnosis of, 
from pregnancy, 138; contractile power 
of, persistent after death, 729; con- 
tractions of, in labor, 479, in post- 
partum hemorrhage, 638-640, in second 
stage of labor, 488, 489, in third stage 
of labor, 489, 490; contraction-ring, 
451-453; cordate, in pregnancy, 320, 
321; digital exploration of , 948; duplex, 
147, 316, in pregnancy, 320; duplex 
bicornis, 316, in pregnancy, 321; 
emptying of, in eclampsia, 354; ex- 
cessive right lateral obliquity of, 649; 
exhaustion of, 622, 623; expression 
of fetus in displacements of, 1033, 
1034; extirpation of, in rupture of, 
646, 647, in puerperal infection, 
819, 820; evacuation of, in post- 
partum hemorrhage, 638; false con, 
tractions of, 481; fetal and infantile, 
319; fluctuations of, in pregnancy, 128; 
hernial protrusion of, in pregnancy, 313, 
314; imperforate, fetal, 319; incarcera- 
tion of pregnant ,307,30 9-3 1 2 , diagnosis 
of, 310, 311, prognosis of, 311, treat- 
ment of, 311, 312; incision of, in Cesar- 
ean section, 1086; increase of, at term, 
102; in different months of gestation, 
86, 88, 89; inertia of, 625-630; in preg- 
nancy, 95-116; involution of, in puer- 
perium, 739-743; irritable, 393; lateral 
displacements of, in pregnancy, 312; 
malformations of, in pregnancy, 315, 
316, 320, 321; massage of, in subinvolu- 
tion, 768; multiparous, description of 
141; murmur, in, in pregnancy, 127, 128; 
muscle of, in puerperium, 742; non- 
development of maternal, effect of, on 
fetus, 303; non-pregnant, enlargements 
of, 136; normal size with extra-uterine 
conditions, simulating pregnancy, 138; 
origin of, 60; partial or complete inver- 
sion of, cause of intra-partum hemor- 
rhage, 730; parturient, three properties 
of, 227; penetrating wounds of gravid, 
417; perforation of, after interrupted 
pregnancy, 398; position of, in dif- 
ferent months of pregnancy, 137; preg- 
nant, parts of, 227; prolapse of preg- 
nant, 312, 313; pubescent, 319; puer- 
peral, description of, 141; repair of 
mucous membrane of, after confine- I 
ment, 747; retraction of, 626; retrodis- 
placements of, a cause of fever in 
puerperium, 814, effect of , on fetus, 308, 
postural treatment of, 941; retroflexion 
of, in pregnancy, 308-312; retroversion 
of, in pregnancy, 308-312, cause of 
urinary retention, 360, posture in, 943; 
rheumatism of muscle of, in pregnancy, 
314; rudimentary, 317-318; rupture o'f, 
641-647, a cause of fever, 813, 814, diag- 



nosis of, from accidental hemorrhage, 
241, in osteomalacia, 384, indications 
for extirpation in, 1097, spontaneous, 
417, spontaneous in pregnancy, 315; 
shape of, in different months, 88, 89; 
sinking of, in labor, 483; size of, at end 
of puerperium, 733, at fortieth week, 
733, in different months, 88, 89; souffle 
in, in pregnancy, 127, 128; sutures 
in, in Caesarean section, 1086, 1087; 
tamponade of cavity of, 960; tetanoid 
action of, 627; tetanoid state of, 623; 
topographical relations of, at term, 
115, 116; torsion of, in pregnancy, 313; 
trismus of , cause of dystocia, 663; uni- 
cornis, in pregnancy, 321, 414, 415; 
vessels of, in puerperium, 742 ; virgin, 
102, 103; walls of , in labor, 453, 454, 
455; weight of, at end of puerperium, 
733, at fortieth week, 733. 

V. 

Vaccination in pregnancy, 379. 

Vaccinia in pregnancy, 286; of fetus, 286. 

Vagina, abnormal terminations of, cause of 
dystocia, 669; absent, 319, 320; bacteri- 
ology of, 777 ; and cervix, tamponade of, 
960; and vulva, dilatation of, 974, 975, 
rigidity and atresia of, cause of dystocia, 
668-670; antepartum irrigation of, 523- 
525; atresia of, 320, cause of dystocia, 
668, 669; bacteriology of, in pregnancy, 
152, 153; changes of, in pregnancy, 128; 
cicatricial stricture of, cause of dys- 
tocia, 669; color of, in pregnancy, 91; 
condition of, in menstruation, 2 1 ; dan- 
ger of examination of, in pregnancy, 
153; deformities of, 320; development 
of, 60; disinfection of, in forceps opera- 
tion, 1063, in puerperium, 738; exami- 
nation of, in pregnancy, 1 53, 173-183; 
exploration of, in placenta pragvia, 229; 
hernia of, 726; incisions of, 978; imper- 
foration of, cause of dystocia, 668, 669; 
in pregnancy, 91; incision and drainage 
of in puerperal infection, 819; lacerations 
and contusions of, 650, 651; malignant 
disease of, cause of antepartum hemor- 
rhage, 420; obstruction of, treatment of, 
670; origin of, 60; prolapse of, in preg- 
nancy, 322; relation of, to pathogenic 
organisms, 7 7 5-7 7 9, repair of, 1103; rudi- 
mentary, 319, 320; secretion of, in preg- 
nancy, 152, 153; septa of , 274; septa of , 
cause of dystocia, 669; small, cause of 
dystocia, 668; structural alterations of, 
cause of dystocia, 668, 669. 

Vaginal and vulval thrombosis, cause of dys- 
tocia, 670. 

Vaginal, Caesarean section, 1088; douche 
(method of Kiwisch) , 961; drainage in 
puerperal sepsis, 819; examination in 
pregnancy, 173-183; hernia, 726; lacera- 
tions, 650, 653, 1099, repair of, 1098, 
1099; irrigation in puerperal endome- 
tritis, 790, 792; secretion in pregnancy, 
152, 153; tampon, 952, 953, 960. 

Vaginismus, cause of dystocia, 668. 

Vaginitis, cystic, in pregnancy, 322; granu- 
lar, in pregnancy, 92 ; specific, in preg- 
nancy, 322. 



1152 



INDEX. 



Vaginofixation, labor after, 658, 659. 

Vagino-perineal incision, 979, 980. 

Vagino-perineal lacerations, 654, 1099. 

Valve, eustachian, 81, 82. 

Vaporization in septic endometritis, 821; in 
septic phlebitis, 803. 

Varicella, fetal, 289. 

Varicosities, in pregnancy, 91, 133, 3 2 3, 3 69; 
of legs, in pregnancy, 177; of umbilical 
vein, 256; rupture of, cause of intra- 
partum hemorrhage, 730. 

Variola, in newly born, 873; in pregnancy, 
286, 378, 379; of fetus, 285; puerperal, 
805; sine exanthema, 286. 

Vas deferens, origin of, 60. 

Vectis, 983. 

Vegetations, vulval, in pregnane}', 323. 

Vein, effect of air in, 930; placental "circu- 
lar," 71; primitive jugular, 81; umbili- 
cal, 81, 82. 

Veins, excision of, as preventive of puerperal 
pyemia, 820, 821; in puerperal infection, 
820, 821; infusion of, in puerperal in- 
fection, 817; omphalomesenteric, origin 
of, 78; vitelline, 78, 79, origin of, 78. 

Velamentous insertion of cord, 252, 253. 

Vense cavse, fetal, 81. 

Ventricles, fetal, 81. 

Ventrofixation, in rupture of uterus, 1097, 
and ventrosuspension followed by preg- 
nancy and labor, 657-659. 

Vernix caseosa, origin of, 85; removal of, 

.di- 
version, 987-1005; bipolar, in placenta pras- 
via, 234, 237; cephalic (see Cephalic 
version) ; combined or bipolar cephalic 
(see Bipolar cephalic version) ; combined 
or bipolar podalic (see Bipolar podalic 
version) ; contraindications to, in pla- 
centa praevia, 236, 237; definition of, 
history of, classification of, frequency 
of, indications for, 987; external ceph- 
alic (see External cephalic version) ; in 
breech presentation, 589; in brow pres- 
entation, 560; in cancer of uterus, 663, 
664; in case of monsters, 617, 618; in 
congenital hydrocephalus, 619, 620; in 
delayed labor, 630; in eclampsia, 356; in 
face presentation, 571; in impacted 
shoulder presentation, 1004; internal 
cephalic, 992, 993; internal podalic (see 
Internal podalic version) ; introduction of 
hand in, 988, 989; in interlocking of fetal 
heads, 614; in Naegele's pelvis, 683; in 
pelvic deformity, 716, 718, 720-723; in 
pelvic presentation, 589; in persistent 
occipito-posterior position, 601, 602; 
in placenta praevia, 236, 237; in pro- 
lapse of arms, 573, 574; in prolapse of 
umbilical cord, 579 ; in rupture of uterus, 
646, 647; in shoulder presentation, 597; 
in threatened rupture of uterus, 645 . 646 ; 
in transverse engagement of head in in- 
let in deformed pelvis, 605, 608; pelvic 
(see Pelvic version) ; podalic, in placenta 
praevia, 234; posture in, 989, 991; po- 
dalic (see Podalic version) ; prognosis of, 
1004, 1005; sling in, 1080; spontaneous, 
in shoulder presentation, 593; varieties 
of, 988. 
Vertex, of fetal skull, 459. 
Vertex presentation, diagnosis of, after 



labor, 514, in labor, 513, 514, etiology 
of, 501; frequency of, 501, causes of 
frequency of, 473, 474; prognosis of, 513. 

Vertigo in pregnancy, 377. 

Vesical, calculus in pregnancy, 361, cause 
of dystocia, 671,672; hemorrhoids - in 
pregnancy, 361; irritation in pregnancy, 
359; neoplasms and traumatisms in 
pregnancy, 361. 

Vesicle, blastodermic, 63; chorionic, 46; 
umbilical, 71. 

Vesicular mole, 209. 

Vicarious menstruation, 25. 

Vienna method of internal cephalic version, 

993- 
I Villi, anchoring, 70; chorionic, 46; history 
of, 68, 69, 70; hydatidiform degeneration 
of, 209; myxomatous degeneration of, 
j 209. 

Virginity, signs of, 31. 

Vision, disturbances of, in pregnancy, 119. 
1 Vitelline, stalk, 56; veins, origin of, 78. 

Vitellus, 44. 
! Volvulus, congenital, ,295; in newly born, 
922. 
Vomiting, in hydatidiform mole, 2 1 1 ; in newly 
born, 919; in pregnane}*, 118, 336, 337, 
exaggerated, ^^y, in phlegmasia alba 
dolens, 803; physiological, 336; relieved 
by posture, 941; in sapremia, 806. 
Vomiting, pernicious, in labor, 728; in preg- 
nancy, 338-344, diagnosis of, 342, due to 
metritis, 315, due to toxemia, 327; eti- 
ology of, 338; induction of labor in, 343, 
prognosis of, 342 ; rectal feeding in, 
symptoms of, 340; treatment of, 

343- 

Vulva, aseptic preparation of, 1 54 ; atresia of, 
320; bacteriology of, 777 ; changes in, in 
pregnancy, 127; condition of, in men- 
struation, 21 ; dressing of, at completion 
of third stage of labor, 548, in puer- 
perium, 750; hematoma of, 670; in preg- 
nancy, 81; micro-organisms in secretion 
of, 153; oedema of, in pregnancy, 323, 
324; preliminary dressings of, 542; 
pruritus of, 323; rigidity of, cause of 
dystocia. 670; secretion of, 153. 

Vulval, douche, 949; lacerations, 653, 654. 

Vulvo-perineal lacerations, 654. 

W. 

Walcher's position, 427, 437, 937, 938, 943; 
in forceps delivery, 947; in labor, 944; 
in pelvic application of forceps, 107 1; 
in pelvic deformity, 716, 722. 

Walcher-Trendelenburg posture, 943. 

Waldeyer's description of ovum of fourth 
week, 83. 

Walking, in pregnancy, 192, difficulty of, 
117; difficulty of, in subinvolution, 137. 

Wasting, simple, of newly born, 924. 

Water, in diet, of pregnancy, 192, 193, of 
prematurity, S69; in diarrhoea of newly 
born, 92 1 ; mineral, in threatened eclamp- 
sia, 351; sterile, in obstetrics, 815, 816, 
in intrauterine irrigation, 951. 

Waters, bag of, at birth, 66. 

Weaning, 862. 

Weight, fetal, 88, 89, 469, 470, 850; in puer- 
perium, 737; of newly born, 850; pla- 



35i: 
342, 



INDEX. 



1153 



cental and fetal, relationship between, 

222. 
Wet-nurse, 854. 

Wharton's jelly, 71; formation of, 85. 
Whey, 745- 
Whisky in convulsions of newly born, 923; 

in puerperal infection, 817. 
White infarcts of placenta, 249, 250. 
Widal's reaction with fetal blood, 287. 
Wigand-Martin method in breech presenta- 
tion, 1050, 1054. 
Winters', formulae for home modification of 

milk, 857; tabular guide for artificial 

feeding, 858. 
Wolffian body, formation of, 60; duct, 

formation of, 58. 



Wounds, fetal, 300, 301 

gravid uterus, 717. 
Wry neck, traumatic, 897. 



penetrating, of 



Yellow fever, in pregnancy, 289; of fetus, 289. 
Yolk sac, 63, 65; mammalian, 56; origin of, 
61. 



Zona pellucida, 43; radiata, 43. 
Zoosperm, maturation of, 44; origin of, 60. 



Appendix (1105-n 12 



Card index case for obstetrical histories, 1105. 
Cards for history records, 1105. 
Chart for institutional and educational work, 
1108-1112. 



History cards, method of using, 1106-1112. 
History records, 1106-1112; in private prac- 
tice, 1105-1108. 



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